69421 Meeting the Challenges of Health Transition in the Middle East and North Africa Building Partnerships for Results – Time for Strategic Action June 2010 Human Development Department Middle East and North Africa Region Vice President: Shamshad Akhtar Chief Economist: Ritva Reinnika Sector Director: Steen Jorgensen Sector Manager/Team Leader Akiko Maeda ACRONYMS AND ABBREVIATIONS AHRQ Agency for Healthcare Research and Quality BOD Burden of Disease CVD Cardiovascular Disease DALY Disability Adjusted Life Years GCC Gulf Cooperation Council GDP Gross Domestic Product GNI Gross National Income HTA Health Technology Assessment IBRD International Bank for Reconstruction and Development ICT Information and Communication Technology IDA International Development Association IMR Infant Mortality Rate MENA Middle East and North Africa MIS Management Information System MMR Maternal Mortality Ratio NHA National Health Accounts NCD Noncommunicable Disease NGO Nongovernmental Organization OECD Organization of Economic Cooperation and Development OOP Out of Pocket RTI Road Traffic Injuries TFEC Traffic Fatalities Economic Cost TFR Total Fertility Rate U5MR Under-five Mortality Rate UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization YLL Years Life Lost i TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS ............................................................................................................................... i TABLE OF CONTENTS ....................................................................................................................................................... ii ACNOWLEDGEMENTS ....................................................................................................................................................... v EXECUTIVE SUMMARY ....................................................................................................................................................... vii Chapter 1: Introduction and Overview........................................................................................................................ 18 I. Overview..................................................................................................................................................................... 18 II. Objectives of the Report ....................................................................................................................................... 21 III. Organization of the Report ............................................................................................................................. 22 Part 1. Drivers of Change: The Impact of the Health Transition ....................................................................... 23 Chapter 2. The Unfinished Agenda of Maternal and Child Health and Nutrition ....................................... 23 I. Maternal and Child Health................................................................................................................................... 23 II. Investing in Child Nutrition in MENA – an Forgotten Agenda.............................................................. 30 A. The Status of Child Malnutrition in MENA Countries.......................................................................... 31 B. The Primary Causes of Child Malnutrition .............................................................................................. 33 C. Micronutrient Deficiencies: A Hidden Type of Hunger ...................................................................... 35 D. Targeted Nutrition Interventions Reap High Returns on Investment ......................................... 38 E. The High Costs of Doing Nothing: Need for Action Now ................................................................... 41 III. Stopping the Silent Spread of HIV/AIDS Epidemic .............................................................................. 42 Chapter 3. Emerging Challenges of Health Transition ........................................................................................... 44 I. Consequences of Epidemiologic and Demographic Transition ........................................................... 44 II. Road Traffic Injuries .............................................................................................................................................. 47 A. Burden of Road Traffic Injuries .................................................................................................................... 47 F. The High Cost of Doing Nothing: Potential Economic Impact of Road Traffic Accidents ..... 51 G. Building institutional and management capacities for road safety ............................................... 53 H. Focus on Results in Road Safety................................................................................................................... 54 III. Meeting the Challenges of Non-communicable Diseases................................................................... 57 A. Overview ................................................................................................................................................................ 57 B. Addressing the NCD Challenge: Managing the Risk Factors............................................................. 60 C. Next Steps: Strategies for NCD Prevention, Control and Case Management ............................ 69 Part 3. Measuring Health Systems Performance and Preparing to Meet the Emerging Challenges .. 78 Chapter 4. Understanding the Equity Implications of Out-of-Pocket Health Expenditures .................. 78 ii I. An Overview of Poverty and Health in the MENA Region ...................................................................... 78 II. Coverage and Access to Healthcare in the MENA Region ....................................................................... 79 III. Trends in Out-of-Pocket Spending by Households .............................................................................. 81 IV. Assessing the financial burden of healthcare spending ..................................................................... 86 V. Next Steps................................................................................................................................................................... 88 A. Meeting the Challenges .................................................................................................................................... 88 D. Focus on results –Steps to Reduce Financial Risks Due to Illness and Injuries ....................... 89 Chapter 5. Aspiring for better health system performance for better health in MENA .......................... 91 A. Why emphasis on health system performance? .................................................................................... 91 VI. What is meant by performance? .................................................................................................................. 92 E. Salient performance issues in MENA ......................................................................................................... 96 A. Management of non-communicable diseases – Diabetes Case Management in Egypt .......... 98 B. Measuring client satisfaction and quality of primary health care services in Alexandria and Menoufia Governorates, Egypt ............................................................................................................................ 100 C. Improving the Quality and Efficiency of Hospital Services – A Tunisia Case ......................... 102 D. Measuring Quality of Care - Patient Responsiveness ...................................................................... 105 E. Measuring Quality and Efficiency in the Pharmaceutical Sector ................................................. 110 F. Patient Safety in MENA ................................................................................................................................. 112 VII. Summary of Evidence and Next Steps .................................................................................................... 113 Chapter 6. Creating Incentives for Better Results – Health Financing Reforms in MENA................... 118 I. Regional Trends in Health Care Financing ................................................................................................ 118 II. An Overview of the Health Financing Systems in the Region ............................................................ 126 B. Predominance of Government-administered Healthcare Services ............................................ 126 G. Challenge of Expanding and Diversifying the Revenue Base for Health ................................. 126 H. Expansion of Social Health Insurance Programs in the MENA Region ..................................... 127 I. Limited Role of the Private Sector in the Provision and Financing of Healthcare ............... 128 III. Preparing the Health Financing Systems to Meet the Emerging Challenges of Health Transition in MENA ...................................................................................................................................................... 128 A. Expanding the revenue base to meet the expected rise in demand for healthcare and expansion in supply of healthcare services ................................................................................................... 129 B. Improving the organization of risk pools for extending financial protection and health service coverage more efficiently ...................................................................................................................... 130 C. Improving the value for money through strategic allocation of health resources and strategic purchasing of health services ........................................................................................................... 131 Part 4. Meeting the Challenges – Charting the Way Forward ....................................................................... 132 Chapter 7: Building Partnerships for Results – Time for Strategic Action ................................................ 132 I. Window of Opportunity .................................................................................................................................... 132 iii II. Building Partnership for Results ................................................................................................................... 134 III. Recommendations for Strategic Action ................................................................................................. 139 References ............................................................................................................................................................................. 175 iv ACNOWLEDGEMENTS This report benefited from contribution to the technical briefs and background reports from the following persons: Child Malnutrition – Christine McDonald, Nutrition Specialist and Caroline Ly, Nutrition Economist who prepared the technical brief, and Yoonyoung Cho, Economist, and Bechir Rassas, Nutrition Economist, who prepared an earlier background report. Road Traffic Injuries – Adnan Hyder, Johns Hopkins University Bloomberg School of Public Health Noncommunicable Diseases - Enis Baris, Sr. Health Specialist, MNSHD; with background report prepared by Sylvia Robles, Johns Hopkins University Bloomberg School of Public Health; and Michael Engelgau, Sr. Public Health Specialist, SASHD. Equity and Out-of-Pocket Payment – Heba Elgazzar, Health Economist, MNSHD; with contributions from Firas Raad, Sr. Health Specialist, MNSHD. Measuring Quality and Efficiency of Healthcare – Enis Baris and Akiko Maeda, with technical notes prepared by Andrew Parkes, Health Policy and Pharmaceutical Specialist. Healthcare Financing – Bjorn Ekman, Sr. Health Economist, with technical inputs from A. Nandakumar, Brandeis University. Majdi Al-Toukhi contributed sections on patient safety and provided feedback on the overall message of the Report. Kimie Tanabe, Economist, MNSHD, contributed to the preparation of statistical tables and data collection. The organization of the report and the main messages emerging from the report benefited from the pre-conference meeting and discussions during the Middle East and North Africa Health Policy Forum Conference which took place in Amman, Jordan on June 6 – 8, 2010. Some of the initial findings of the report is being taken forward by the MENA Health Policy Form. v vi EXECUTIVE SUMMARY The Unfinished Agenda and Emerging Challenges of Health Transition Significant achievements in improving health outcomes The Middle East and North Africa Region1 is a heterogeneous region, comprising the lower income countries2 of Yemen and Djibouti in the south; the middle income countries from Morocco in the west to Iran in the east, and the oil-producing high income countries of the Gulf Cooperation Council (GCC) countries. In its recent history, the MENA Region has made a remarkable progress in expanding access to basic health services for its citizens, and the Region can be justifiably proud of having achieved one of the fastest rates of decline in child mortality among all the developing regions of the world. These accomplishments are particularly noteworthy in that the Region maintained a steady mortality decline despite of the periods of stagnation in economic growth that have affected different parts of the Region over this period. They reflect the benefits of past investments in basic health services and the beneficiary effects of the broader social and economic development, such as improved access to safe drinking water and hygiene as well as the higher educational attainment of girls – all of which are known to have a positive impact on child and maternal health. These past achievements form an important basis for addressing future challenges. On the one hand, there are persistent inequities in the status of women and children’s health which warrant special attention, as they highlight areas where past efforts have not yet succeeded in achieving desirable results and call for renewed commitments as well as innovative approaches. At the same time, the benefits of economic development are bringing new risks and health issues that will require substantial realignment of the existing policies and programs. MENA region has one of the youngest population in the world: this provides a window of demographic opportunity to prepare the next generation of children and youth for a healthy and productive adulthood, and avoid the unnecessary suffering and heavy cost of modern diseases. At the same time, the healthcare system will also need to be prepared to provide adequate financial protection and quality healthcare as the ageing population will require increasing support to avoid premature deaths and minimize the suffering from disabilities associated with chronic diseases and injuries. The unfinished agenda - addressing the persistent inequities in maternal and child health outcomes Notwithstanding the impressive achievements at the regional level, high rates of maternal and child mortality persist in many parts of the region. This is especially pronounced in the lowest income countries of Yemen and Djibouti, but high levels of maternal and child mortality rates persist also among vulnerable population groups in a number of middle income countries in the region, such as in rural Morocco and Upper Egypt. The people living in Iraq have experienced reversals in health outcomes in recent years due to conflict-related problems, and similar reversals may emerge in conflict affected areas such as the Gaza Strip. Despite evidence of improvements in recent years, there is evidence that women in the Region still face specific socio-cultural barriers: women face 1 MENA Region includes the following countries/territories (in alphabetical order): Algeria, Bahrain, Djibouti, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Malta, Morocco, Oman, Palestinian Territories (West Bank and Gaza), Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, and Yemen. 2 According to the World Bank definition, low income economies have 2008 GNI per capita $975 or less; middle income $976 - $11,905; and high income, $11,906 or more. vii particular challenges in terms of accessing healthcare and having appropriate knowledge and information about their own health and the health of their own children. The unfinished agenda – attending to the neglected problems of child malnutrition Malnutrition among women and children remains a serious but largely neglected problem in the MENA Region. While more children are now surviving to adulthood in the Region, many of them suffer the deleterious and long-term consequences of malnutrition which deprive them of having equal opportunities for social and economic development. Yemen carries the unfortunate distinction of having the second highest rate of child stunting (malnutrition) in the world, and the recent trends suggest that the situation is not improving. Child malnutrition - including micronutrient deficiencies such as Vitamin A deficiency and anemia - also persists in a surprising number of countries across the region, including middle and high income countries. Child malnutrition not only increases the risk of child illness and deaths, but malnutrition occurring in the critical period during pregnancy and from 0 - 2 years of age irreversibly lowers the child’s future learning and productive capacity. Thus, addressing early child malnutrition will have long-term social and economic benefits that go well beyond the immediate health of the affected individual. Low birth-weight and associated perinatal conditions remain the second highest cause of death in the region. For a region that has already shown itself capable of achieving significant improvements in the health of the population, the persistence of such basic health problems presents a conundrum: how can the considerable resources and capacities in the region be mobilized to fill these gaps in basic health outcomes? Impact of health transition on changing health risks, burden of disease and social and economic burden on the people In addition to the unfinished agenda discussed above, the MENA region is facing an additional set of challenges that will profoundly affect people and the economies and societies of the region. These challenges can be identified as a number of transitions pertaining to different social and economic dimensions, including life-styles and health related behaviors, increases in income and subsequent demands for health care, and demographic and epidemiological changes. Rising incomes and urbanization are leading to substantial transformations in lifestyles which, in turn, are generating new health risks and changing the nature of demand for healthcare. These changes are evident, for example, in the rapid increase in obesity rates and the increasing rates of tobacco smoking, especially among women and adolescents. This is leading to a rapid increase in the prevalence of noncommunicable diseases (NCDs) such as heart diseases – already the leading cause of death in the MENA region at 60 percent of deaths and expected to increase further to 77 percent of total deaths by 2030. If no action is taken to mitigate the risk factors contributing to NCDs, the direct and indirect costs of healthcare and disease could be substantial. The growing urbanization and increase in traffic volume in the absence of adequate road safety functions has also contributed to high rates of road traffic injuries (RTIs), which is now the third highest cause of death in the region and also predicted to increase between 30 – 40 percent by 2030 if no action is taken to change the current policies in place. The new patterns of disease will have a profound impact in many dimensions: for the individuals and families, it will increase the burden on families due to premature deaths or disabilities – leading to potential loss of income and the added cost of treatment and indirect cost of caring for family members suffering from disabilities due to chronic illness or injuries; for the state, it would mean a rising demand for better health care and added pressure to cover these additional costs of care through government budget, and the potential loss of revenues due to premature deaths and disabilities of working age population, and for the employers and businesses, it would mean lower viii margin of profit as the cost of labor increases to cover the higher cost of healthcare, health insurance, or losses in productivity due to worker illness or disability. From “Youth Bulge� to “Middle Age Bulge� – Implications on development opportunities for today’s children and youths The MENA region currently has among the youngest population in the world, which is helping to keep down the demand for and costs of healthcare. But over the coming decades most MENA countries will face the effects of declining fertility rates and ageing population. Moreover, as noted above, there is evidence that this new cohort of ageing population may have higher rates of chronic conditions compared to their predecessors, due to higher rates of risk factors such as smoking and obesity. The high rates of malnutrition – both under- and over-nutrition – among the current cohort of children will also increase their likelihood of chronic noncommunicable diseases as well as irreversibly affect their capacity to learn and participate fully in the economic and social life of their community. As this cohort of children and youth move into middle-age, international evidence suggests that it will lead to a substantial increase in demand for and cost of healthcare unless actions are taken now to promote healthy lifestyles, reduce the population’s exposure to risk factors, and improve the capacity of the healthcare system to prevent, screen and manage the treatment of illness in the early stages. Measuring Performance for Results – How ready are the MENA countries to meet these new challenges? In view of the unfinished agenda and emerging challenges discussed above, the critical question becomes how ready are the governments and healthcare systems in the MENA region to meet them? While many countries of the region clearly possesses some important strengths, a careful and critical review of the performance of the existing health systems reveals a number of issues that may constrain the countries’ capacities to respond effectively to these challenges. Status of Equity and Financial Protection in Health – a Leaky Safetynet Most MENA countries have established a network of publicly subsidized services, complemented in some countries by social insurance schemes. Overall, most MENA countries have officially a system in place that are intended to offer near universal coverage for basic health care at no or only a small formal cost at the point of use. Yet, a review of available data in the low and middle income MENA countries suggests that a significant number of households face financial barriers in accessing healthcare, which may lead to some individuals foregoing needed care, and others to expend a significant part of the household budget on medical payments. The relatively large size of out-of-pocket (OOP) spending in most of the low and middle income MENA countries indicates the absence of effective health risk sharing arrangements. In a number of countries the share of OOP has been decreasing (Algeria, Libya, Lebanon, Djibouti, Iraq and Yemen) suggesting some improvements in the risk pooling and exposure of the citizens to catastrophic payments. In others (Egypt, Iran, Jordan, Morocco, and Tunisia) this share is increasing, which may be interpreted as a critical challenge in these countries. Finally, most GCC countries show relatively low OOP payments, suggesting that their health coverage is relatively high, although data on access to healthcare among different categories of beneficiaries, including expatriate workers, were not available to allow any conclusions to be drawn. ix A further important finding is that there is evidence in some countries that catastrophic payments for healthcare are occurring not only among the poor, but also among the near-poor population groups, and that a significant number of near-poor fall below the poverty line as a result of health expenses. This is a critical observation given that this group is large in the MENA region. These trends suggest that the risk pooling mechanisms may not be functioning adequately to confer financial protection at all levels of income groups. Care must be taken in interpretation of these results, and more detailed analysis will be needed to confirm these findings, but they suggest the potential magnitude of the problem may be extensive, and that social targeting of healthcare services will need to be extended not only to the poor but to the near-poor population groups. Status of the quality of care – a worrisome picture A review of the health systems performance in the MENA Region shows that the data on healthcare are generally focused on indicators related to inputs and supply of services, but the quality and efficiency dimensions of healthcare are rarely monitored routinely. While a number of initiatives are being taken to address these issues in the Region, the state of health care monitoring, research and evaluation in the areas of quality and efficiency remains fragmented and very limited in scope. Few assessments are carried out to review the entire set of dimensions that should be included in assessing the “quality� of healthcare, namely:  safety (for patients and providers);  effectiveness (clinical efficacy);  timeliness;  efficiency; and  patient-centeredness (responsiveness to patient needs, preferences) Due to the paucity of data on service utilization and quality, including cost of care, only a partial picture emerges as to the performance of healthcare in the region. The available evidence suggests the following issues: (i) Patient safety issues, while assumed to be part of the regular management and operations at the facility level, are not yet part of the national priorities in most MENA countries. Key indicators such as adverse drug effects, nosocomial infection, and other iatrogenic errors are not regularly monitored or publicly reported and the magnitude of the problem remains largely unknown. (ii) While most countries have introduced some standards for clinical guidelines and protocols, their application in evaluating the performance of the healthcare system remains limited. These efforts also appear to be fragmented by different specialities or disease groups, and few countries in the region have taken the initiative to prioritize the development of national guidelines based on epidemiological trends analysis, or to link their use with performance evaluation and payment or resource allocation mechanisms. (iii) Timeliness of care includes not only the waiting times at the point of service, but the patient access to early screening and treatment. There is evidence that chronic disease patients are not diagnosed in the early stages of the diseases, and enter healthcare only at the later stages of the disease when treatment becomes much more costly and prognosis poor. Many patients, especially among the lower income groups, may be foregoing care due to financial reasons or for other socio-cultural barriers to care: the implications of this foregone care on their burden of disease and subsequent social and economic conditions remain uncertain and warrant further examination. x (iv) Most public sector healthcare providers do not have the capacity or the organizational structure to evaluate the actual cost of care (versus budget expenditures) for a service output or to compare the quality and appropriateness of the outputs against quality standards. Thus, neither the healthcare provider nor the payer are certain whether they are overpaying or under-financing services, or whether the healthcare providers are meeting the quality standards in the most efficient manner. There is also very little monitoring and evaluation of the efficiency and quality of care in the private sector. This is particularly notable in the pharmaceutical sector, where prices in the private sector in many MENA countries are significantly above international prices, and the use of generics is limited. Since a significant share of out-of-pocket health expenditure in the MENA region occurs for the purchase of pharmaceuticals, this has implications on people’s access to healthcare. (v) A number of countries are beginning to require healthcare providers to collect information on patient satisfaction and responsiveness. However, it is unclear how or whether this information is being used to influence the performance of the healthcare providers and to empower patients and improve their experience with the healthcare providers. Trends in healthcare financing in the MENA region – efficient use of resources, or underfinancing of care? A review of the healthcare financing trends in MENA region over the past 15 years and its comparison with the global trends reveal the following characteristics. At all levels of income, the MENA countries have been spending a relatively smaller share of the economy on health measured as a percentage of GDP. What is particular to the MENA region is that while the rest of the world has shown a significant increase in the level of spending on healthcare between 1995 and 2008 as a share of GDP at all levels of income, the MENA countries on average have shown no change or a relative decrease in health spending as a share of the total economy. At the same time, the level of public spending on healthcare as a share of total government spending has been low relative to the rest of the world, while private out-of-pocket spending has been high. The last decade was a period of relatively high GDP growth rates in the MENA Region: thus, while there was a real per capita increase in health spending in all the MENA countries, the rate of increase did not keep pace with the economic growth rates, resulting in an overall slight decline of health spending as a share of GDP. These trends might suggest, at an initial glance, that the governments in the Region have managed to contain costs and potentially delivered services efficiently. However, as discussed above, there is evidence of inefficiencies and quality issues in the healthcare system that suggests that cost-containment is not necessarily leading to better results, and that some of the costs are possibly being shifted to patients. Egypt, Morocco, Tunisia and Yemen also showed significant increase in out-of-pocket spending as a share of total health spending. These trends would indicate that at least in these countries, there may be an increasing cost-shifting of healthcare to the patients, leaving them more vulnerable to potential catastrophic health expenditures. This indicates that the risk pooling mechanisms are not keeping pace with the rising demand for healthcare in these countries. The high income Gulf Cooperation Council countries remain an exception, as they have considerable fiscal space and are able to extend coverage to their residents. However, even in these countries, the issue of quality of care has become a major issue and questions are being raised whether the resources are being spent well. xi Limited role of the private sector in the provision and financing of healthcare While the private healthcare providers and private health insurers have been expanding to some extent in a number of MENA countries, their growth has been relatively slow. In addition, many countries report that the private health markets are only partly or weakly regulated. As will be discussed in more detail below, the MENA region also has limited private insurance market, with preponderance of private spending still coming from direct household out-of-pocket spending at the point of services as was described above. To be able to meet the increased demand for health services and the likely need for expansion in the supply of certain types of services, the MENA region will need to develop clear strategies and policies for harnessing the private health care sector. Few countries in the region explicitly include the private sector providers as an integral part of the national strategic plan to expand coverage and improve the performance of the healthcare system as a whole. Some of the health reform initiatives in the region are expanding contracting of private providers by social insurance funds or directly by the Ministries of Health, but apart from initiatives in Lebanon and to some extent the Palestinian Authority, the number of initiatives in the region remains very limited. A preponderance of private providers in the region are small-scale dispensaries and physician offices, many of which are run by public-sector physicians conducting private practice after hours. With the growth in income and demand for care among the population, opportunities exist to support a growing number of organized, large-scale private health care providers that could offer effective alternatives, or complements, to publicly administered healthcare delivery system. There are potentially missed opportunities for engaging all the stakeholders in the sector towards the achievement of the national goal- that of ensuring access to and use of quality healthcare for all the population. Next Steps – Window of Opportunity for Strategic Action An ounce of prevention is better than a pound of cure: promoting primary prevention through intersectoral action and primary health care A healthy transition from the Youth bulge to Adult age bulge is imperative for MENA countries if they are to maximize their social and economic gains from the demographic dividend and generate wealth. Health systems have a major role to play in this regard, not only through the provision of quality health services, but and perhaps equally importantly through a well conceived vision, strategy and public policies. Primary prevention, the avoidance or mitigation of the occurrence and incidence of a disease, plays a very important, if not primordial, role in this regard. There are really two sides to the coin of primary prevention in anticipation of the emerging NCD epidemic: (i) through healthy intersectoral public policies aiming at promoting population health, aiming at the four behavioral risk factors, namely smoking, physical inactivity, inappropriate diet (including both under nutrition and obesity) and risky driving: and (ii) through interventions aiming at improving health of the individuals, namely, screening, counseling and primary care services to advocate for behavioral change. Primary prevention is not always less costly, if health benefits as measured in terms of quality adjusted life years (QALYs) are assessed against direct (health care) costs. About 20 percent of some 300 preventive interventions are considered to save costs in the long run. However, primary prevention is almost always cost effective, especially it is well targeted to high risk population groups and if indirect costs due to loss of productivity are also accounted for. xii MENA countries are well positioned to advocate for primary prevention for a number of reasons. The literacy rates are high for mass scale public information education and communication (IEC) programs, and the region has relatively good media coverage. School enrollment rates are high for targeted interventions on tobacco control, diet and nutrition. Institutional capacity for improved road safety is existent. And health systems are relatively well endowed for primary prevention in primary care setting. The challenges therefore is more about leadership in setting the right vision and strategies for effective advocacy for healthier public policies and gradual transformation of health systems to make them more attuned to providing primary care. Linking priority public health programs and the expansion of health coverage for the vulnerable population A number of countries in the region are beginning to address the need to improve the social targeting mechanisms and ensure a more effective allocation of subsidies. As these subsidy reforms are introduced and implemented, it would be important to ensure that the priority health policies and programs are explicitly included as the recipients of these additional resources. This will require strong justifications in terms of the cost-effectiveness of the interventions and the long- term benefits in terms of economic impact and social welfare gains that will accrue as a result of investing in these health policies and programs. Among the priority programs that should be in this list would include funds to subsidize access to basic health coverage for the poor and the near- poor, as well as public health programs that will promote healthy lifestyles and prevent health risks. It should be emphasized that social targeting on its own - while necessary - will not be sufficient for achieving behavioral changes on the part of both the beneficiaries and healthcare providers. The actual availability of services in the under-served areas and the appropriate use of healthcare services by under-served population groups will require an active program of incentives to the providers to be responsive to patient needs and preferences, and empowerment of the citizens. Expanding the revenue base and improving risk pooling to meet the expected rise in demand for healthcare With the advent of noncommunicable diseases and ageing effects on top of income growth, it is expected that the demand for healthcare will grow, and Governments in the Region will come under increasing pressure to broaden the benefits covered under state-guaranteed health plan to include a wider range of high cost medical interventions. At the same time most MENA countries will need to aim at reducing the share of direct out-of-pocket health spending by individuals and either organize them under some form of prepayment risk-pooling schemes or replace them with subsidies if they are poor or vulnerable. Given that most MENA low and middle income countries have very limited fiscal space to increase the fiscal allocation to cover these additional resource requirements, alternative options will need to be considered: (i) There are opportunities to organize at least part of the current relatively large out-of- pocket expenditures – which represent the household’s willingness to pay for services – into better organized risk pools. One option being considered by a number of countries in the region is to introduce new, or expand the existing, social health insurance schemes. However, this approach carries a number of risks, especially in most low and middle income MENA countries which have many unemployed and informal labor markets. A contributory social insurance system risks excluding from the risk pool the poor and unemployed who are unable to contribute, introducing distortions in the labor market, e.g., by discouraging workers from participating in the formal sector to avoid xiii the additional tax on labor, and increasing administrative complexity by adding another level of organizational structure for collection and management of funds. (ii) Another option would be to improve the organization and regulation of the private health insurance market to enable households to direct their out-of-pocket spending on health into the purchase of a prepayment program. Some groups could be encouraged to purchase supplementary health insurance to provide coverage for services outside of the state-guaranteed benefits package. But this will require considerable investments in institutional capacity and regulatory systems in order to achieve effective results and avoid the risks of market failure, including adverse selection and moral hazard problems. (iii) There are also opportunities to broaden the revenue base for health through the introduction of taxes on certain goods and services that have a direct impact on public health. This could include tobacco excise taxes and VAT, which would have the effect of reducing the demand for tobacco. The revenues from this source could be applied towards subsidizing health care for priority public health programs (e.g., tobacco cessation program) and to subsidize priority population groups. In the MENA region, the current price of cigarettes inclusive of tax is extremely low, and other forms of tobacco (e.g., the use of shisha) are not taxed. The exact scope for increasing revenues through this mechanism in the MENA region needs to be assessed in each country and given the cost-effectiveness of tobacco excise taxes, it is recommended that this is done across the region. Furthermore, the Report has shown that most countries in the Region have segmented health systems and multiple risk pools that operate independently from each other and with limited coordination or harmonization of rules across the different funds. This not only increases the administrative complexity and overall cost of the health system, but also creates barriers for the citizens who must move across the different risk pools (e.g., moving from student status to informal employment, formal employment, and unemployment, and eventually to retirement). These groups would benefit from ease of portability of benefits across the different categories. Introduction of consistent and transparent rules and regulation across the different health funds or health subsystems will facilitate the monitoring and evaluation of the performance among these different risk pools, and ensure their contributions towards the national goals of ensuring equitable, affordable and quality healthcare for all the citizens. Improving quality of care – engaging the professionals in the continuous quality improvement process and creating incentives towards patient-centered care Most governments in the MENA region still operate through an administrative, line-item budget process that focuses on limited categories of inputs (wages, operating expenses and capital investments), and which does not allow much scope for resource allocation based on performance. This also holds for the health sector, and there is evidence to suggest that this form of administrative structure and process is not effective at monitoring and detecting deficits in the performance of the healthcare services, or to take corrective action when they occur. International experiences show that allocating resources based on outcome and performance targets can have a large impact on the quality of health services, reduce unnecessary or wasteful use of services, and thereby add value for both patients and providers. Opportunities exist for most MENA countries to improve the performance of the health sector benefit by moving towards more strategic allocation of health resources within the existing envelope of resources. Against the expected substantial increase in the overall spending on healthcare in the coming decade, it will be even more critical to xiv ensure that the capacities and mechanisms are in place to improve performance before adding to the scope of services. Specifically, this will involve the introduction of performance based payments or contracting of services, either with private providers, or through internal allocation of resources within the public sector. Paying providers based on performance will require changes to the way the civil service is managed and regulated in many countries. Furthermore, introducing contracting would open up the possibility to create more efficient markets for health care where private providers can operate and provide the state-financed services along with public providers. This could potentially increase the supply of core services that can meet the increasing demand as incomes grow and disease patterns change. The complexity and dynamic nature of healthcare will be accelerated by the advent of noncommunicable diseases and the growing demand for greater choice and access to high- technology healthcare. In the middle and high income countries around the world, there is a growing trend towards the establishment of independent assessment agencies as a way of independently monitoring and evaluating the quality of services provided by healthcare organizations. Examples of such agencies include accreditation organizations, food and drug authorities, and health technology assessment agencies. These types of agencies are growing in number and influence around the world and they provide valuable professional assessments of various aspects of healthcare. The governance structure of these entities will be critical: ensuring a balanced representation of stakeholders will make certain the credibility and independence of these agencies. Such agencies can play a critical part in enhancing accountability, by developing locally adapted performance standards, benchmarking health care providers against these agreed standards, and providing educational support for the professionals operations. A number of countries in the MENA region are beginning to initiate the establishment of such organizations, for example, accreditation agencies and food and drug authorities, but the process may need to be accelerated. Strengthening Health Intelligence for sound decision making and evidence based partnership Timely and accurate information is a necessary, although not always sufficient condition for sound decisions. This is all the more critical in pluralistic health care systems to function effectively where market conditions are not always ideal and that there usually is a asymmetry of information among its multiplicity of partners. Policy makers, healthcare managers, health insurance fund holders, and the patients need to assess how well the healthcare system is performing, what are its strengths and weaknesses, and what actions need to be taken to address deficits in performance. This will require a fundamental shift from the traditional approaches to health information systems, which invariably focus on inputs to account for the budget, payroll, infrastructure, consumables towards a more user friendly, timely and relevant information system on service use in all its facets (volume, intensity, distribution, mix, technical quality, appropriateness, timeliness etc) and on patient health outcomes. Moreover, data would have to be aggregated or dis-aggregated (e.g., region, hospitals, primary care, diabetic patients, etc) in accordance with the needs and demands of various partners. In addition, there is a growing need for population based information as a result of increased concern for global health security (e.g., Avian influenza, H1N1 etc). Finally, it is equally important to gauge the health status of the populations through periodic and issue-specific (e.g. nutrition, maternal health, etc) surveys to complement the information base and triangulate administrative data with primary data for drawing a better and more accurate and precise picture of the health, use of health services, and health system xv performance. A modern health management information system will enable managers to undertake concurrent review and assessment of the service performance, and allow better control and timely decisions over clinical management process (for managers of health facilities), the healthcare financing process (for healthcare payers), and public health reporting (for surveillance and other public reporting requirements such as international health regulations). Investments in these tools, both in infostructure (hardware) and the institutional and human capacity to collect, compile, synthetize, report and interpret the information (software) for decision making at all levels of care will be vital for improving accountability in the system and evaluating performance on a continuous basis. Building Partnership for Results – Time for Strategic Action This report has highlighted the many impressive improvements in population health across the MENA region over the past decades. These achievements are due to many factors, including investments in education, water and sanitation, and broad access to basic health care for most citizens. At the same time, it identified a number of critical areas of unfinished agenda and emerging challenges associated with the health transition that warrant attention by policy makers and other stakeholders. The MENA region has the window of opportunity to take strategic action now, during this period of “demographic opportunity�, while the population is relatively young and healthy and the risks can be modified or averted. Actions taken today will have the salutary effect of preventing premature mortality and morbidity in the future, thus avoiding the future costs of treatment and long-term care of chronic conditions. This will require foresight and committed leadership at all levels of the society, and a greater understanding of the underlying causes of the risk factors in the MENA context. The rise in the prevalence of many of the risk factors can be traced to behavioral consequences of a multiplicity of causes: increased international trade (e.g., access to tobacco products, processed foods), migration (urbanization and sedentary lifestyle), changes in living conditions (e.g., sedentary work and living environment) and in the production, marketing and availability of goods (e.g., processed food). Potential solutions are bound to be context specific, but in all cases it will require partnerships among the key stakeholders: policy makers, professionals, business leaders, communities and the public. Success will depend on countries setting up effective institutional structures and processes that will enable different stakeholders to come together on a shared agenda: to agree on common goals, standards and actions, continually adapt to the changing needs of the population and demands created by new technologies, and be accountable to each other with respect to their own areas of responsibility and expertise. Delaying actions at this time will surely place the well-being of the next generation of children and youth into jeopardy. The time for strategic action is now to ensure that they will have the opportunity to participate fully in the social and economic life of their community. Policy Goals Meeting the Challenges Forging Partnerships Raise public Raise public support for and mobilize Forge new partnerships with media, awareness political leadership to support preventive civil society, business leaders, political health leaders. Enhance economic Link expansion of priority public health Engage Ministries of Finance, xvi and fiscal programs and health coverage with Commerce, Social Affairs, Labor sustainability ongoing national strategies on subsidy and social safety net reforms; include strategic public health programs for priority investment Mitigate health risks Ensure that expansion of healthcare Engage Ministries of Finance, risks of poverty and coverage is closely linked with social Commerce, Social Affairs, Labor extend social targeting mechanisms and social programs protection for health that help to direct subsidies to poor and near-poor and assure their access to better care; and extend insurance coverage to non-poor Mitigate risk factors Improve the knowledge and understanding Undertake behavioral research with of the socio-cultural and environmental social scientists and design public factors that affect behavior and exposure to health programs that affect behavior; health risks, and develop effective social design safe roads with transport policies and programs that have impact. engineers; monitor progress with interested stakeholders Engage Ministries of Education, Agriculture, Industry, Commerce, Interior Mobilize business and Foster Corporate Social Responsibility Promote private-public partnerships, community leaders to towards safe and healthy work engage local community organizations support public health environment and healthy school and NGOs goals environment; expand community outreach programs Reorient health Create incentives for preventive primary Engage medical schools, professional systems care among health professionals and associations, health insurers/payers. promote patient-centered care; instill culture of continuous quality improvement and greater accountability on health care performance. xvii Chapter 1: Introduction and Overview I. Overview Significant achievements in improving health outcomes. The Middle East and North Africa Region3 is a heterogeneous region, comprising the lower income countries4 of Yemen and Djibouti in the south; the middle income countries from Morocco in the west to Iran in the east, and the oil-producing high income countries of the Gulf Cooperation Council (GCC) countries (see Box 1 and Table 34). In its recent history, the MENA Region has made a remarkable progress in expanding access to basic health services for its citizens, and the Region can be justly proud of having achieved one of the fastest rates of decline in child mortality among all the developing regions of the world. The achievement is particularly noteworthy in that the Region maintained a steady rate of mortality decline in spite of the periods of stagnation in economic growth that have afflicted different parts of the Region over this period (see Figure 1). They reflect the benefits of past investments in basic health services and the salutary effects of the broader social and economic development, such as improved access to safe drinking water and hygiene as well as the higher educational attainment of girls – all of which are known to have a positive impact on child and maternal health. The unfinished agenda. Notwithstanding the impressive achievements at the regional level, high rates of maternal and child mortality persist in parts of the MENA region – mainly in Yemen and Djibouti, but also among vulnerable population groups in the middle income countries. The people living in Iraq have experienced reversals in health outcomes in recent years due to conflict-related problems, and similar reversals may emerge in conflict affected areas such as the Gaza Strip. Yemen carries the unfortunate distinction of having the second highest child malnutrition rate in the world, but child malnutrition also persists in significant numbers in some of the middle income countries in the MENA region. Child malnutrition increases the risk of child illness and deaths, and may be an underlying cause of slowdown in child health. Moreover, child malnutrition – especially during the critical period during pregnancy and from 0 - 2 years of age – severely constrains the child’s future learning and productive capacity: for this reason, addressing early child malnutrition will have long-term social and economic benefits that go beyond the health of the individual. Low birth-weight and associated perinatal conditions are the second highest cause of death in the region. Timely access to healthcare may be more problematic for women, who face particular social and other barriers to access. For a region that has already shown itself capable of achieving significant improvements in the health of the population, the persistence of such basic health problems presents a conundrum: how can the considerable resources and capacities in the region be mobilized to fill these gaps in the basic health outcomes? Impact of Epidemiologic and Demographic Transition. The successes of the past development efforts are also bringing about profound changes to the types of health problems affecting the people in the Region. Rising incomes and urbanization are leading to 3 MENA Region includes the following countries/territories (in alphabetical order): Algeria, Bahrain, Djibouti, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Libya, Malta, Morocco, Oman, Palestinian Territories (West Bank and Gaza), Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, and Yemen. 4 According to the World Bank definition, low income economies have 2008 GNI per capita $975 or less; middle income $976 - $11,905; and high income, $11,906 or more. 18 substantial transformations in lifestyles which, in turn, are generating new health risks and changing the nature of demand for healthcare. These changes are evident, for example, in the rapid increase in obesity rates and the increasing rates of tobacco smoking, especially among women. This is leading to a rapid rise in the prevalence of Noncommunicable Diseases (NCDs) such as heart diseases, which is currently the leading cause of death in the region. The growing urbanization and increase in traffic volume in the absence of adequate road safety functions has also contributed to high rates of Road Traffic Injuries (RTIs), which is now the third highest cause of deaths in the region. Demographic Dividend – A Time for Strategic Action. The MENA region currently has among the youngest population in the world, which is helping to keep down the cost of and demand for healthcare. But over the coming decades most MENA countries will face the effects of declining fertility rates and ageing population. Moreover, there is evidence that this new cohort of ageing population may have higher rates of chronic conditions compared to their predecessors, due to higher rates of risk factors such as smoking and obesity. As the size of middle-aged and elderly population grows, it will inevitably lead to an increased demand for and rising costs of healthcare. Figure 1: Trends in under-five mortality and GDP per capita for selected regions, 1960-2005 Source: Table from unpublished manuscript by Geir Solve Sande Lie, “Economic Growth and Under Five Mortality Rates in Middle East and North Africa, and Gulf Cooperation Countries,� The World Bank, 2010. 19 What are the implications of these changes on the healthcare system? The healthcare systems in the MENA region had developed over the years to address communicable diseases and maternal and child health issues which had been the predominant health concerns in the preceding decades. The substantial shift in demand towards the prevention and treatment of noncommunicable diseases and managing chronic disabilities caused by NCDs and road injuries will impose new demands on the organization and management of healthcare system. It will require the system to develop new capacities on a number of fronts: to engage citizens more actively to have them take early preventive measures – often years before any symptoms might appear; to monitor and treat individual patients on a continuous basis and help them manage their chronic conditions over their lifetime; and to invest in population-based programs that promote healthy behaviors and mitigate health risks that contribute to noncommunicable diseases, such as tobacco smoking. The ageing population and the expected rise in noncommunicable diseases will intensify the demand for healthcare, not only in terms of access to basic services but also for greater choice of, and access to, new medical technologies. The rapid pace of scientific discoveries in the biomedical field is bringing tremendous opportunities for reducing the burden of diseases across the globe. Yet the speed with which these new medical innovations are being introduced into the global market is often outpacing the capacities of most national authorities – even those in high income countries –to evaluate and regulate in order to assure their safety, efficacy and cost-effectiveness. While new global efforts are being initiated to address these challenges, regulating the influx of new medical technologies and managing their safe and affordable application will present a substantial challenge for the MENA countries. This, in turn, will further intensify pressures on national authorities to expand the breadth and depth of healthcare services covered under state-guaranteed or state-subsidized health programs. It will also increase the need to establish an effective social insurance mechanism to protect the citizens against catastrophic payments in the event of illness or injury. Meeting this growing demand for a more comprehensive health care coverage within fiscally sustainable levels will be a major challenge. How ready are the MENA countries to meet these new challenges? The MENA Region represents countries at widely different levels of income levels and health outcomes, therefore, the capacities to address the unfinished agenda and meet the emerging challenges will differ according to each country’s own resources. Box 1, below, groups the countries broadly by income levels and special conditions (conflict-affected countries). This report will review the trends in the health of the population and available evidence on the performance of the current healthcare system, and identify areas of opportunities and constraints in meeting the new health challenges. Box 1: Broad Subgroups of MENA Countries Low-income population (Yemen, Djibouti): Child and maternal mortality rates remain very high among the lowest income countries of the region (Yemen, Djibouti). Access to basic health services remains a challenge for these population groups. Djibouti is also the only country in MENA to face an epidemic stage of HIV/AIDS. It should be noted that maternal and child mortality rates remain very high among some subpopulations of the middle income countries (e.g., rural Morocco and Upper Egypt), and require special attention. 20 Middle-income population (Morocco, Algeria, Tunisia, Libya, Egypt, Jordan, Lebanon, Syria, and Iran): This group of countries faces a rapid rise in non-communicable diseases and injuries-related conditions as a share of the total disease burden. These conditions are leading to increasing costs and complexities in healthcare that will require substantial investments in modern business functions, information systems and new regulatory structures to ensure quality, safety, equity and efficiency of services. A number of countries are examining healthcare as a contributor to economic growth, with a potential capacity to generate high value employment and expand the role of the private sector. Conflict-Affected areas (Palestinian Territories of West Bank & Gaza; Iraq): The health outcomes have faced reversals in these populations as a consequence of conflict-related problems, and will require special attention and support in addressing the needs of the most vulnerable and affected people, and in rebuilding their healthcare systems. Gulf-Cooperation Council (GCC) Countries: These high income oil-exporting countries have health outcomes that approach the levels of developed economies. They now face very high rates of non-communicable diseases among the national population, and a strong and growing demand for higher quality and more responsive health care services. These countries also have a large expatriate working-age population whose health care coverage is a topic of ongoing national discussion. II. Objectives of the Report This Report is intended to inform the policy makers and other key stakeholders in the MENA region to both the unfinished agenda and the emerging challenges that are currently affecting the health of the people in the MENA region, and the likely impact they will have on their health and what would be necessary to respond to these challenges in the coming decade. Specifically, the Report aims to: (i) draw attention to the unfinished agenda of maternal and child health, with particular focus on child malnutrition which continues to affect the most vulnerable population in the MENA Region; (ii) review the trends in epidemiologic and demographic transition, highlighting the emergence of noncommunicable diseases and injuries as the leading causes of morbidity and deaths and the new demands they will likely place on the healthcare system; (iii) assess the performance of the existing healthcare systems in the Region in terms of equity, efficiency and quality of care – to the extent data are available, and review the organization of the existing healthcare financing system for the purpose of identifying areas of constraints and opportunities to address the unfinished agenda and emerging challenges; and (iv) suggest a series of approaches that may help the countries in the Region come together and support each other in preparing to resolve the current problems and meet the emerging challenges. The health of a nation is everybody’s business: no single individual or group can solve the complex set of issues that are confronting the health of the people of the MENA Region. Thus, meeting the challenge will require building of partnerships among the multiple stakeholders with varying perspectives and interests who are willing to agree on achievement of common goals. The stakeholders may include the Government policy makers involved in providing public health programs and assuring affordable health coverage for the citizens; members of parliament enacting new health laws and regulations; healthcare managers and professionals providing clinical health services in the public and private domains; medical insurers and social insurance fund managers mobilizing revenues and controlling the cost of care for their beneficiaries; business leaders and employers concerned with the health coverage for their employees; and representatives of the civil 21 society interested in protecting the health of and access to healthcare for their constituents. Building an effective partnership among the constituents will be an essential step for achieving better performance in healthcare and better results in health. While international experiences and comparisons can provide insights on the nature of the problem and suggest possible solutions, they are useful only if they can be used as part of an ongoing discussion and debate among the policy makers and stakeholders within their own community. It will be up to the people of the Region to chart their own course towards better results. Within this context, it is hoped that this Report will provide a useful catalyst in bringing together the key stakeholders in the Region for the purpose of defining common challenges and finding joint solutions to improve the health and welfare of all the people of the MENA region. III. Organization of the Report The Report will begin with the discussion on the Unfinished Agenda which focuses on the status of Maternal and Child Health in the region, with particular focus on child malnutrition which has received relatively little attention to date, and will be followed by discussion on the Emerging Challenges from Noncommunicable Diseases and Road Traffic Injuries. Part 3 will review the performance of the current health systems in the Region – to the extent that data are available - in terms of their capacity to provide financial protection on the citizens and ensure quality and efficiency of healthcare services. This section will also analyze the health financing system and describe its capacity to address the emerging challenges. In Part 4 we will summarize the main findings of the study and conclude with suggested areas of priority actions to be taken by the key stakeholders of the region. 22 Part 1. Drivers of Change: The Impact of the Health Transition Chapter 2. The Unfinished Agenda of Maternal and Child Health and Nutrition I. Maternal and Child Health The MENA countries have achieved remarkable improvements in the health status of their people, as evidenced by a more than a ten year increase in average life expectancy between 1980 and 2007 (59 years in 1980 to over 70 years in 2007) and one of the fastest rate of reduction in child mortality rates among the developing regions of the world. Despite this progress, the MENA region includes a number of countries with persistent high rates of child mortality (see Figure 2). Figure 2: Under-5 Mortality Rates in MENA countries, 1990 and 2008 140 120 Deaths per 1,000 live births 100 80 60 40 20 0 1990 2008 Source: (UNICEF, 2009) According to UNICEF and WHO, there are 68 countries around the world that account for 90 percent of total number of children under five (8.8 million children) who die every year. Of these, five countries are in the MENA Region: Egypt, Djibouti, Iraq, Morocco and Yemen. Among these countries, Djibouti, Yemen and Iraq are making insufficient progress to meet the Fourth Millennium Development Goal (MDG4) of reducing child mortality rate by two thirds between 1990 and 2015 (see Table 1, below), and deserve particular attention. Egypt and Morocco had high child mortality rates, but made 23 significant progress in mortality reduction in recent years. It should be noted that according to the criteria used by UNICEF and WHO, Algeria would also fall under the category of “insufficient progress� towards meeting MDG4. However, more recent analysis suggests that Algeria has already reached below 40 per 1,000 live births, putting Algeria “on track� according to the criteria used by UNICEF and WHO to define progress towards MDG4. Table 1: Under-five Mortality Rates and Number of Under-five deaths in 5 MENA Countries with highest impact on contributing to progress towards MDG 4 Under-five Annual Number of mortality rate (per Under-five deaths Country 1000 live births) (thousands) Progress to MDG 4 1990 2008 Algeria* 64 41 30 Insufficient progress Egypt 90 23 45 On track Djibouti 123 95 2 Insufficient progress Iraq 53 48 41 Insufficient progress Morocco 88 54 24 On track Yemen 127 69 57 Insufficient progress Source: (UNICEF & WHO, 2010) Note. According to WHO and UNICEF, “on track� indicates that the under-five mortality rate for 2008 is less than 40 per 1,000 or that it is 40 or more with an average annual rate of reduction of 4% or higher for 1990–2008; insufficient progress� indicates that the under-five mortality rate for 2008 is 40 or more with an average annual rate of reduction of 1%–3.9% for 1990–2008; “no progress� indicates that the under-five mortality rate for 2008 is 40 or more with an average annual rate of reduction of less than 1% for 1990–2008. * Algeria is included in this list since it fulfills the above criteria indicated by UNICEF and WHO. However, more recent data analysis (Rajaratnam, et al., 2010) may suggest that Algeria’s U5MR may already be below 40 per 1,000 live birth, and therefore “on track� to meet MDG4. According to a recent study (Black RE, Cousens S, Johnson HL et al. Global, regional and national causes of child mortality in 2008: a systematic analysis. Lancet; 375:1969-87) 56% of all under five deaths in MENA occur during the first month of life, as mortality in children 1-59 omnths has declined. The under-five deaths in MENA occur mainly as a result of preterm birth complications , asphyxia and neonatal infections, pointing out to the inadequacy of skilled birth attendance and neonatal care as the primary contributing factors. The availability, reliability and validity of data on maternal mortality remains a major issue in countries where vital statistics and data on causes of death are incomplete or unreliable, especially in rural settings. In such circumstances, population based surveys with large sample size are needed to obtain accurate estimates of maternal mortality ratio. A recent study (Hogan, et al., 2010) found that MENA region has the lowest “data density� on maternal mortality among all the global regions. Thus, obtaining accurate and timely data on this indicator is problematic globally, but especially severe in MENA Region which should be a source of major concern to policy makers in the region. In preparation for the countdown to Millennium Development Goal, UNICEF and WHO are undertaking an updated 24 analysis of the data to address these issues, but at the time of this report, the results were not yet available. We present below the data from the recent study by Hogan et al. (see Table 36 in Annex and Figure 3 below) which uses a regression model based on a number of key determinants to estimate Maternal Mortality Ratio (MMR). Despite good progress in almost all MENA countries, especially in Egypt and Morocco, in reducing the maternal mortality (MDG 5), several countries, including Djibouti, Yemen and Iraq, are unlikely to achieve the targeted ¾ reduction in MMR by 2015, unless they overcome health-systems constraints and scale up the implementation of proven interventions aiming at improving reproductive and maternal health. It is important to keep in mind that in principle, nearly the totality of maternal deaths is fully preventable at an affordable cost even in the poorest MENA countries, as prices are falling and external donor aid is more readily available. However, there are many supply- and demand-side barriers such as limited and inequitable access to skilled birth attendance, financial constraints, socio-cultural barriers for women to seek and obtain prenatal care. All these barriers could potentially be removed with high level commitment, leadership and adequate funding universal coverage of family planning, appropriate perinatal care and skilled birth attendance (Travis P, Bennett S, Haines A et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900-06). Egypt, for instance has made notable progress in reducing in maternal mortality ratio over the past decade, through adoption of the safe motherhood strategy that helped increase access to medically assisted deliveries, and the utilization of maternal health care and antenatal care services. The high income GCC countries and some of the middle income MENA countries have maternal and child mortality rates that are approaching the levels of developed economies. Figure 3: Maternal Mortality Ratio in MENA Countries, 1990 and 2008 Maternal Mortality Ratio in MENA Countries, 1990 and 2008 700 MMR per 100,000 live births 600 500 400 300 1990 200 2008 100 0 Source: (Hogan, et al., 2010). 25 Maternal mortality ratio is an indicator of women’s access to health care, and an indirect measure of empowerment in terms of women’s ability to take care of her own health. Another indirect measure of women’s empowerment towards her own reproductive health is their access to family planning and use of contraceptives. Contraception also offers women the benefits of timing and spacing of pregnancies and increased ability to plan the number of their children. Iran has the highest contraceptive prevalence rate as well as the lowest fertility rate in the region, while Yemen and Djibouti have the lowest contraceptive prevalence levels and among the highest fertility rates in the region (see Figure 4). In GCC, the contraceptive prevalence rates are similar to those in the rest of MENA, varying between a low 30 percent in Oman and Saudia Arabia to a higher 50 percent in Bahrain. Figure 4: MENA Countries – Comparing Contraceptive Prevalence Rate (2004-7) and Total Fertility Rate 2008 Non-GCC MENA Countries - Contraceptive Prevalence Rate and Maternal 100 462 Mortality Ratio 500 Contraceptive Prevalence Rate (% woemn ages Maternal Mortality Ratio per 100,000 live 90 80 400 70 60 269 300 50 40 200 births 15 - 49) 30 130 124 20 50 66 100 46 40 35 43 36 10 24 28 0 0 Maternal Mortality Ratio per 100,000 live births (2008) Contraceptive prevalence (% of women ages 15-49) Source: Contraceptive Prevalence Rates 2003-2006 from WHO EMRO Health System Observatory Data Base, 2010; Total Fertility Rates from World Development Indicators, 2010. 26 Figure 5: Global Trends in Total Fertility Rates, 1970 - 2008 Total fertility Rate, 1970-2008 East Asia & 8.0 Pacific 7.0 Europe & Central Asia 6.0 Latin America total births per woman 5.0 & Caribbean 4.0 Middle East & N. Africa 3.0 South Asia 2.0 1.0 Sub-Saharan Africa 0.0 GCC 1970 1980 1990 2000 Source: World Development Indicator, The World Bank, 2010. The MENA Region was a relatively latecomer to the demographic transition process, but between 1990s and 1980s, the region has shown among the fastest decline in total fertility rates (TFR) over the past two decades (see Figure 5). Despite this significant progress, the average TFR among non-GCC MENA countries remains around 2.6 – significantly above the rates of countries at comparable income levels. The high income countries of GCC show an even higher TFR at just above 3, and a relatively low contraceptive prevalence rate compared with the middle income MENA countries. Fertility decline has been significant in early transition countries such as Lebanon, Iran, Tunisia, and Algeria Egypt, but fertility rates remain high in the Palestinian Territory, Djibouti, Iraq, Saudi Arabia and Yemen. The 2008 DHS from Egypt showed that fertility rates have not shown further decline in Egypt, for reason which are still under investigation. Many factors contribute to the continuing high fertility rates, including the low female labor participation rates and an increasing but still early age of marriage as well as relatively low contraceptive prevalence rates. (See (Roudi-Fahimi & Kent, 2007) and (Assad & Roudi-Fahimi, 2007)). Unfinished agenda in ensuring health equity in maternal and child health. The national averages do not give an accurate picture of the underlying health inequities within a country. As in other regions, there is discrepancy in access to health care between rural and urban women. Rural women generally marry at a younger age and have more children. Maternal mortality rates, for example, are generally much higher in rural than in urban areas. It is essential to bring affordable health services closer to rural women to ensure that they receive the care to which they are entitled. Another important factor in the maternal mortality rates is the practice of early marriage in some of the countries of the region, mostly among the poor and the rural populations. This mainly affects already marginalized women (Talevani, 2007). There is evidence of varying degrees of inequities in health outcomes across the region, even among countries that are on track to reach the MDG 4 and MDG 5 targets at the national levels. Djibouti, Yemen and Morocco show significant rural/urban disparities in access to health care as measured by access to birth attendants and in health outcomes as 27 measured by under-five mortality rates (see Figure 6). Djibouti has a unique feature in that the urban population appear to have better access to healthcare but worse outcomes in terms of child mortality. This may reflect the effects of HIV/AIDS on this group of population. When disparities are measured in terms of income groups, these same measures of health service access and health outcomes appear to be much more pronounced between the lowest and highest income quintile groups in Morocco, Yemen and Egypt, but much less so in Djibouti (see Figure 7). Jordan shows good performance in terms of providing equitable access to health care in rural and urban areas, although the disparities in child mortality rates appear to be worse in rural areas, suggesting potential differences in quality of care or other socio-economic factors. Syria appears to have relatively small differences in health outcomes by rural/urban regions or by income quintiles. Figure 6: Geographic disparities in access to healthcare services and health outcomes in selected MENA countries 100 100 Under-5 Mortality Rate (per 1,000 80 80 % Births Attended 60 live births) 60 40 40 20 20 0 0 Rural Urban Rural Urban Source: See Table 38 in Annex for details. Figure 7: Income disparities in access to health services and health outcomes in selected MENA Countries. 100 120 118 Under-five mortality rate % births attended (per 1,000 live births) 80 100 78 80 60 60 49 40 40 22 20 20 0 0 Djibouti Egypt Jordan Morocco Syria Yemen Egypt Morocco Syria Yemen Lowest Quintile Highest Quintile Lowest Quintile Highest Quintile Source: See Table 38 in Annex for details. 28 It should be noted that while Egypt had had significant disparities in access to health services and in health outcomes between rural and urban areas. In recent years, Egypt has made significant progress in reducing these disparities, as is evident in the steady decline in differences in infant and child mortality rates between rural and urban population groups (Table 2) and in the access to and use of maternal health services (Table 3). The lack of consistent and comparable data across all the countries in the region limits the opportunity to compare their performance in terms of equity in access to healthcare and health outcomes. Table 2: Trends in rural/urban inequities in child health outcomes in Egypt, 1992 - 2008 Inequalities in Health Outcomes 1992 2005 2008 Disparity in infant mortality rates (ratio of rural/urban rates) 1.77 1.51 1.20 Disparity in under-five mortality rates (ratio of rural/urban rates) 1.85 1.48 1.24 Source: Calculated from Egypt Demographic and Health Surveys, 1992, 2005 and 2008. Table 3: Trends in maternal health care indicators in Egypt (1995-2008), by residence Percentage of births in the five years preceding Urban Rural Total the survey whose mothers had: Regular Antenatal Care/a 1995 50.0 14.9 28.3 2000 53.9 25.9 36.7 2005 74.8 49.2 58.5 2008 80.5 57.4 66.0 Medically Assisted Delivery 1995 67.9 32.8 46.3 2000 81.4 48.0 60.9 2005 88.7 65.8 74.2 2008 90.2 72.2 78.9 Source: (El-Zanaty & Way, 2008) Note: a. A woman is considered to have had regular antenatal care if she had 4 or more visits during pregnancy. Gender-related barriers to care. Despite this good progress, there is evidence of gender- related barriers to healthcare. In Egypt, when ever-married women were asked in 2008 what barriers exist to constrain them from accessing health care, 80 percent responded that they had encountered at least one serious problem in accessing healthcare for themselves when sick (Table 4). The types of problems facing the women fall broadly under the following categories: perceived quality of care (lack of drugs, availability of female worker), financial constraints (getting money for treatment), social/cultural barriers (getting permission to go for treatment) and physical access (distance to facility). Addressing these constraints will require not only a broader health system response involving improvements in quality of care and patient responsiveness and improved financial protection for the low income groups, but also a better understanding of the socio-cultural barriers to access and 29 active community outreach programs to counter them. These issues will be discussed further in Section 3, below. Table 4: Ever-married women reporting serious problems in accessing health care for themselves when sick, Egypt 2008 Type of Problems Residence Income Quintiles TOTAL Urban Rural Lowest Second Middle Fourth Highest At least one problem accessing 80.2 74.4 84.2 92.0 85.7 83.1 79.0 62.4 health care Concern no drugs available 64.3 59.8 67.4 76.9 68.5 66.7 62.8 47.7 Concern no provider available 63.1 57.1 67.3 71.5 69.2 66.8 61.9 47.1 Getting money for treatment 44.3 34.5 51.2 70.4 55.9 46.8 35.5 16.1 Concern no female provider 40.4 34.4 44.6 51.0 45.3 40.2 37.3 29.5 available Not wanting to go alone 26.2 13.2 23.8 32.9 28.2 26.6 24.3 19.7 Having to take transport 19.5 12.4 20.4 31.0 25.2 21.0 13.9 7.8 Distance to health facility 17.1 12.4 20.4 29.2 21.6 17.5 11.9 7.1 Getting permission to go for 7.2 5.7 8.3 12.6 8.3 6.9 5.1 4.0 treatment Source: Table 11.20 in (El-Zanaty & Way, 2008). II. Investing in Child Nutrition in MENA – an Forgotten Agenda The recent food and fuel crises underscore the importance of investing in human capital, particularly nutrition, as one prong in a long term strategy to strengthen MENA region’s economic base. The crises reflect the multi-dimensionality of the causes and consequences of the region’s poor nutritional status. As the largest net food importer, the MENA region saw its food import bill rise dramatically in 2007-8 with increasing food prices; while oil revenues fell in 20091. Food security is one of the many causes for the region’s nutritional problems and the high dependence on oil revenues reflects the region’s need for a broader reliance on an economically competitive labor force. In particular, child malnutrition has consequences for the region’s long term growth prospects. To address this, the MENA region can make targeted high return investments in interventions to promote optimal child nutrition and stem the current and future economic losses from child malnutrition. The MENA region faces nutritional problems that are found in both developing and developed countries. Eight MENA countries (Djibouti, Egypt, Iraq, Kuwait, Libya, Morocco, Syria and Yemen) have a high burden of child undernutrition, as defined by a rate of stunting and/or underweight of at least 20%. Child undernutrition can increase the risk of morbidity and mortality, impair cognitive development, and reduce economic productivity2,3. Globally, it is responsible for over one-third of child deaths (Maternal and Chlid Undernutrition Study Group, 2008). In addition, nearly every country in the region, 30 including the oil-rich nations, suffers from high rates of overweight or obesity amongst adults. Problems of obesity and overweight may be linked to inadequate nutrition in utero, which exacerbates the region’s increasing burden of non-communicable diseases such as diabetes and cardiovascular disease (Barker, 1995). This “dual burden� of malnutrition calls for a multi-faceted approach, which encompasses a range of cost-effective nutrition interventions delivered during the window of opportunity of child development (i.e., conception to 2 years of age). By ensuring that a child receives proper nutrition along with optimal psychosocial stimulation during this crucial period, it is possible to prevent irreversible damages to a child’s physical growth, cognitive development, and later economic productivity. This section will summarize the nutritional status of countries in the MENA region, identify factors underlying child malnutrition, describe the current coverage rates of micronutrient intervention programs in the region, and present the costs of scaling up a package of interventions that aim to address child undernutrition for five high burden countries, along with the economic rationale for doing so. A. The Status of Child Malnutrition in MENA Countries The regional variability in the prevalence of child undernutrition is striking (see Figure 1). Rates of stunting range from 5 percent in Iran to nearly 60 percent in Yemen5. Similarly, the prevalence of child wasting, an indicator of acute malnutrition, is as low as 2 percent in Qatar and Tunisia, and as high as 17 percent in Djibouti6. International studies have shown that poor fetal growth or stunting in the first 2 years of life leads to irreversible damage, including lower school achievements and reduced adult income (Victora, et al., 2008). There are significant geographic disparities in rates of child undernutrition within several MENA countries. For example, in urban parts of Egypt and Syria, approximately 35 percent of children under five are stunted, whereas in rural areas child stunting rates are 52 percent and 58 percent, respectively6. As a comparison, the average prevalence of child stunting across all developing countries is 32.0 percent2. If one considers the absolute numbers of stunted children in the region, given the large population of Egypt and the now high stunting rates, it is estimated that over 2.64 million children in Egypt are stunted today, which is almost equivalent to the combined number of 2.7 million stunted children under the age of 5 in three countries in the MENA region which have historically had high stunting rates: Morocco, Yemen and Djibouti5,25. Thus, reversing the trend of increased stunting in Egypt alone could achieve a significant impact on the number of children who are stunted in the region as a whole. For this reason alone, Egypt needs to be seen as a priority country for nutrition interventions in the Region. An examination of nutrition trends according to economic status reveals the fact that undernutrition is not merely a matter of poverty. Even in a high-income country such as Kuwait, nearly one-quarter of all children under five are stunted. Furthermore, within a country, rates of undernutrition can still be high amongst the wealthier segments of society. For example, in Yemen and Egypt rates of child stunting among the wealthiest quintile are 53 percent and 27 percent, respectively. 31 Figure 8: Prevalence of Underweight, Wasting and Stunting in MENA Region Prevalence of Underweight, Wasting, and Stunting 60 50 Underweight % of children under 5 40 Wasting 30 20 Stunting 10 0 High Burden Level of Undernutrition Source: Stunting and underweight rates were obtained from World Health Statistics 20105. Wasting rates were obtained from the UNICEF’s 2009 State of the World’s Children6. Rates are based on the 2006 WHO Child Growth Standards. Note: Data were not available for the West Bank and Gaza. Rates of underweight were not available for Iran, Qatar, Bahrain, United Arab Emirates, or Kuwait. Compounding the persistent problem of child undernutrition is the growing and concurrent problem of over-nutrition in the MENA region, creating a “dual burden of malnutrition� (see Figure 9). Rates of overweight and obesity are escalating among both pediatric and adult populations in several countries. In Lebanon, Syria, Egypt and Libya, more than 15 percent of children under-five years of age are overweight (World Health Organization, 2010b). The epidemic of adult obesity is more widespread. While obesity rates tend to be higher among women than men, over 15 percent of the adult male populations in Egypt, Iraq, Jordan, Kuwait, Saudi Arabia and Syria are obese. 32 Figure 9: The Dual Burden of Malnutrition in MENA Countries The Dual Burden of Malnutrition Child Overweight 50 45 40 Child Stunting 35 Prevalence (%) 30 25 Adult Obesity (Females) 20 15 10 Adult Obesity (Males) 5 0 Average Child Tunisia Djibouti Libya Syria Saudi Arabia Algeria Iraq Egypt Jordan Morocco Lebanon Overweight Among Low- and Middle-Income Countries Source: World Health Statistics 20105. Child stunting and overweight rates are based on the 2006 WHO Child Growth Standards. Note: Child overweight data were not available for Bahrain, Iran, Kuwait, Oman, Qatar, United Arab Emirates or the West Bank and Gaza. One factor which may underlie the dual burden of malnutrition is low birthweight. In the MENA region, rates of low birthweight range from 5 percent in Tunisia to 32 percent in Yemen6. Research has found that infants who receive suboptimal nutrition in utero and are born with a low birthweight, but who experience rapid weight gain in childhood (after 24 months) are at an increased risk of obesity and associated non-communicable diseases (NCDs) such as type 2 diabetes and cardiovascular disease in adulthood2,4. As will be discussed below, in the MENA region, NCDs already account for over 65 percent of deaths and their prevalence and associated health care costs are expected to rise. Egypt, for example, can expect a three-fold increase in diabetes and a four-fold increase in related hospital visits from 2000 to 203023. B. The Primary Causes of Child Malnutrition While there are a number of broad systemic issues that influence the poor nutrition outcomes in the MENA region, the primary causes of child malnutrition include the following: Poor Infant Feeding Practices: Rates of exclusive breastfeeding are low across the MENA region (see Figure 10). Proper feeding practices during infancy are essential to ensuring optimal 33 nutritional status during the early years of a child’s life. Exclusive breastfeeding is recommended for the first six months, as it provides all required nutrients, boosts the immune system, and protects against exposure to pathogens found in contaminated water. From six months of age, appropriate complementary foods should be provided along with breast milk, and breastfeeding should be continued until at least two years of age. Data from Djibouti, Eqypt, Iraq, Jordan, and Syria show that, respectively, 77, 85, 91, 77, and 66 percent of children six to nine months of age are breastfed with complementary food. However, the low rates of exclusive breastfeeding during the first six months imply that many infants are receiving other foods or liquids besides breast milk too early. This highlights the necessity to provide education and support to mothers and families about the benefits of exclusive breastfeeding. Figure 10: Exclusive Breastfeeding in the MENA Region Exclusive Breastfeeding is Low Across the Region 60 % of children under 6 months 50 40 30 Global Average 20 10 0 Djibouti Syria Algeria Tunisia Iraq Yemen Jordan Morocco Egypt Source: World Health Statistics 20105. Note: Rates of exclusive breastfeeding were not available for Bahrain, Kuwait, Lebanon, Libya, Oman, Qatar, Saudi Arabia, United Arab Emirates or the West Bank and Gaza. High Disease Burden: Rates of infectious diseases and preventable illnesses such as diarrhea and pneumonia remain high in some MENA countries, particularly among the low income groups. For example, in Djibouti and Yemen, 38 percent of deaths among children under five are caused by diarrhea and pneumonia combined (World Health Organization, 2010b). There is a close link between undernutrition and infection: undernutrition can increase the severity of an infection, while additional nutrients are required to fight an infection subsequently increasing the risk of undernutrition. In addition, infants born with a low birth weight and those who are not exclusively breastfed are more vulnerable to contracting an infection. Preventing and treating infections contributes to combating undernutrition. 34 Limited Access to Nutritious Food: The recent economic crisis has heightened the risk of food insecurity in many MENA countries. According to the Food and Agriculture Organization’s 2009 State of Food Insecurity Report, more than 30 percent of the population is undernourished in Djibouti and Yemen7. Rising food prices often force families to purchase nutrient poor foods and limit dietary diversity, which can increase the risk of micronutrient deficiencies. Household Behavior and Local Practices that affect Nutrition. Guaranteeing food security must be addressed, but it is not a sufficient solution since much of the poor nutritional outcomes are often due to practices within the household and communities, including breastfeeding and weaning practices. The practice of chewing qat in Yemen among breastfeeding mothers, for example, can significantly exacerbate the nutritional status of their infants. Social outreach programs, education and other multi-sectoral approaches are needed to ensure that all household members, and in particular, infants, children and women, have access to an adequate, nutritious, and diverse diet. In addition, the growing problem of obesity in the MENA region points to a nutrition transition in which modern diets composed of more sugar, refined grains, and fat have been adopted in lieu of healthier traditional diets that consisted of more whole grains, fruits and vegetables8. While this report has highlighted the potential risks of malnutrition, it will require more targeted research will be required in this area to identify these constraints and develop locally adapted and socially responsible interventions. C. Micronutrient Deficiencies: A Hidden Type of Hunger Micronutrient deficiencies are widespread in the MENA region and represent an invisible type of malnutrition. Deficiencies in vitamins and minerals such as vitamin A, iron, zinc, and iodine can impair child growth and cognitive development and increase the risk of disease2. Young children and pregnant women are particularly vulnerable to certain micronutrient deficiencies, given the increased nutrient demands associated with such periods of rapid growth and development. At the population level, micronutrient deficiencies have severe economic repercussions. For example, childhood anemia alone is associated with a 2.5 percent drop in adult wages9. Figure 4 illustrates the prevalence of vitamin A deficiency among preschool-aged children and pregnant women across several MENA countries. It is notable that rates are consistently high among pregnant women, ranging from 15 percent in Iran to 24 percent in Jordan10. However, rates appear to vary more amongst pre-school aged children. Less than 1 percent of children in Iran are reported to have vitamin A deficiency, whereas the rate among Moroccan preschool-aged children is over 40 percent10. 35 Figure 11: Vitamin A Deficiency in Preschool-Aged Children and Pregnant Women in the MENA Region High Rates of Vitamin A Deficiency Among Preschool- Aged Children and Pregnant Women Persist 40 Prevalence (%) 30 20 10 0 Oman Syria Djibouti Iran Libya Saudi Arabia Algeria Tunisia Yemen Iraq Egypt Jordan Lebanon Morocco Preschool-Aged Children Pregnant Women Source: WHO Global prevalence of vitamin A deficiency in populations at risk 1995-200510 Note: Data were not available for Bahrain, Kuwait, Qatar, United Arab Emirates, or the West Bank and Gaza. As shown in Figure 5, rates of anemia are exceptionally high in many MENA countries. Although there are different causes of anemia, it is generally estimated that approximately half of all cases are due to dietary iron deficiency. In 16 of the 18 countries with available data, more than one-quarter of preschool-aged children and pregnant women are anemic11. In Djibouti and Yemen, the rate of anemia among preschool-aged children has reached 66 percent and 68 percent, respectively11. Such high rates are of concern given the close association between anemia and reduced cognitive performance. A recent review found that 19 of 21 studies reported poorer mental, motor, social, emotional, or neurophysiological functioning in infants with iron deficiency anemia than those without26. 36 Figure 12: Anemia among Preschool-aged Children and Pregnant Women in the MENA Region Anemia Among Preschool-Aged Children and Pregnant Women is High Across the Region 70 60 Prevalence (%) 50 40 30 20 10 0 Oman Djibouti UAE Libya Kuwait Saudi Arabia Syria Qatar Algeria Tunisia Bahrain Iraq Iran Egypt Jordan Yemen Lebanon Morocco Preschool-Aged Children Pregnant Women Source: WHO Worldwide prevalence of anemia 1993-2005: WHO global database on anemia. Note: Data were not available for the Palestinian Territories. While data are lacking for other types of micronutrient deficiencies, some recent estimates on zinc status have reported that 42 percent and 61 percent of the population is at risk of insufficient zinc intake in Morocco and Egypt, respectively12. Zinc has been proven to be effective in reducing morbidity from diarrhea as well as promoting child growth27. Coverage Rates for Micronutrient Interventions: Where does MENA stand? The promotion of a diversified diet amongst all members of the population should underlie all efforts to improve micronutrient status. However, in certain settings, supplementation for vulnerable subgroups and fortification of staple foods with particular micronutrients is also necessary. For example, vitamin A supplementation of children 6-59 months of age has been proven to reduce rates of child mortality by 23 percent13. Iron folic-acid supplementation during pregnancy lowers the risk of maternal mortality due to hemorrhaging, and reduces the chance that the infant will be born prematurely, with a low birthweight, or with a neural tube defect14. In the MENA region, some countries have begun micronutrient supplementation or fortification programs to help prevent micronutrient deficiencies. Egypt, for example, has a large-scale flour fortification program that has achieved great success in providing additional iron to the diets of the poor population via wheat flour which is used for baking subsidized baladi bread. With financing from the Global Alliance for Improved Nutrition, Morocco has been able to fortify more than 80 percent of industrial flour and approximately 90 percent of table oil. Additional efforts are currently underway to expand coverage of flour fortification to small artisanal mills and also to develop new fortification vehicles, such as couscous, milk and sugar. Table 1 presents coverage rates of vitamin A supplementation, salt iodization, and the status of 37 national flour fortification policy for countries with available data. However, further expansion of these programs is needed in order to achieve universal coverage, which could be accomplished yielding highly cost-effective outcomes. Table 1: Coverage rates of micronutrient interventions in selected MENA countries Country % of children 6-59 months % of households Type of wheat flour of age who received full consuming iodized salt fortification policy coverage of vitamin A Algeria - 61 - Bahrain - - Mandatory Djibouti 17.9 - - Egypt 12.4 25 Proposed Iran - - Mandatory Iraq 2.0 69 Mandatory Jordan - 80 Voluntary Kuwait - - Mandatory Lebanon - 92 - Libya - 90 Proposed Morocco 25.5 91 Mandatory Oman - - Mandatory Qatar - 69 Mandatory Saudi Arabia - - Mandatory Syrian Arab Republic 2.9 46 Proposed Tunisia - - Mandatory United Arab Emirates - - Voluntary Yemen - - Mandatory Sources: Vitamin A supplementation coverage rates were obtained from World Health Statistics 20105. Salt iodization coverage rates were obtained from UNICEF’s 2009 State of the World’s Children6. The status of flour fortification policy was obtained from the Micronutrient Initiative’s Investing in the Future12. Note: Data were not available for the West Bank & Gaza D. Targeted Nutrition Interventions Reap High Returns on Investment MENA’s child malnutrition must be addressed through both nutrition-related policy reforms and targeted interventions. Complex socio-economic factors help explain existing nutrition outcomes. For example, Egypt’s obesity problem has been in part blamed on food subsidies for energy dense, nutrient-poor foods which increase the relative price of healthier fruits and vegetables15. In some cases, low female participation in decision making hinders the ability of mothers to make optimal nutrition decisions. At the country level, a close examination of policies that impact nutrition outcomes such as food pricing, agricultural policies, securing access to water, and strengthening primary care access, delivery and public health networks needs to be accomplished in conjunction with expanding nutrition interventions. When the MENA region is viewed as a whole, selected nutrition issues are consistently apparent: child stunting, overweight, and iron deficiency anemia need to be prioritized as problems that require immediate action. Interventions that aim to address these problems should have both child protection and gender components. Furthermore, to have the greatest impact, interventions should be targeted at children under five years of age as well as women of 38 childbearing age, with particular attention to children under the age of two and adolescent females. In order to reach these vulnerable subgroups, strategies must engage multiple actors including care providers, family members, policy-makers and influential groups, local communities, and the general public. In countries with a high burden of child undernutrition, scaling-up a set of ten proven nutrition interventions has been recommended to reduce mortality, improve health outcomes, and strengthen human capital16. Although the specific package of interventions should be tailored to the context of each country, Table 2 summarizes the ten proven interventions, highlights their cost-effectiveness, and estimates the costs of scaling up from existing coverage levels to full coverage of the target populations in Djibouti, Egypt, Iraq, Morocco, and Yemen 5. The individual country-specific costs are detailed in Annex The interventions for improving micronutrient status yield enormous benefits and are especially cost-effective, generating returns on investments greater than those of programs for water and sanitation, and governance and corruption17. For example, achieving universal salt iodization would impact nearly 60 million additional people in Djibouti, Egypt, Iraq, Morocco, and Yemen at a cost of under US$3 million which would yield a benefit:cost ratio of 30:112. Expanding the use of multi-micronutrient powders would lead to a benefit of $12.20 per Disability Adjusted Life Year (DALY) saved20. These ten interventions vary in their impact and cost-effectiveness. Vitamin A, zinc supplementation and treatment of acute malnutrition have lower costs per DALY. Other interventions such as iron fortification, salt iodization may have higher costs per DALY but have primary impacts on productivity and GDP16. 5 Details of the interventions, target populations and costing methodology can be found in Scaling Up Nutrition: What will it cost? and at: www.worldbank.org/nutrition/profiles 39 Table 2: Targeted Nutrition Interventions For Djibouti, Egypt, Iraq, Morocco, and Yemen Intervention Unit Cost (US$) Approximate Total Cost of Numbers of Costs as % of Return on Scaling Up children or Government Investment (US$) people Health (%) or cost currently Expenditures28 effectiveness uncovered (US$)12, 20,21,22 who will be reached by scaling up the interventions 1. Community 16.50/child under 1400 342,853,500 21 million 2% nutrition programs 5/year children under for behavior change 5 years of age 2. Vitamin A 2.64/child aged 6- 1700 24,975,743 9.5 million <0.5% supplementation for 59 months/year children 6-59 children aged 6-59 months of age months 3. Therapeutic zinc 2.20/child aged 6- Up to 1370 40,685,282 18.5 million <0.5% supplementation for 59 months/year children 6-59 children 6-59 months of age months 4. Multi- 7.92/child aged 6- 3700 (iron) 41,063,807 5.2 million <0.5% micronutrient 23 months/year $12.20 per children 6-23 powders DALY saved months of age 5. Prophylactic 0.55/child aged 600 2,962,868 5.387million <0.5% deworming 12-59 months/year children aged 12-59 months of age 6. Iron-folic acid 4.40/pregnant or $65-115 per 12,467,884 2.8 million <0.5% supplementation for lactating DALY saved pregnant and pregnant and woman/year lactating lactating women women 7. Iron fortification 0.20/person/year 800 9,599,000 48.0 million <0.5% of wheat flour people 8. Salt iodization 0.05/person/year 3000 2,926,262 58.5 million <0.5% and iodized oil people capsules 9. Complementary 0.40/underweight 85,958,973 1.7 million 0.5% food for the child 6-23 months children of 6- prevention and of age/day 23 months of treatment of age moderate acute malnutrition 10. Treatment of 200/child treated $41 per DALY 87,674,683 438,000 0.5% severe acute saved children 6-59 malnutrition months of age TOTAL 651,168,000 3.8% 40 Source: The set of interventions, unit costs, and return on investment estimates were obtained from Scaling Up Nutrition: What will it cost?16. Methodology for the cost estimates can be found at: www.worldbank.org/nutrition/profiles E. The High Costs of Doing Nothing: Need for Action Now Poor nutrition can take a sizable financial toll on economic growth resulting in billions of GDP lost in the MENA region. In the absence of scaled-up dedicated nutrition programs, undernutrition levels would likely decline only at half the rate of per capita economic growth18. For the high burden countries in the MENA region such as Djibouti and Yemen, their current pace of slow or stagnating progress in child undernutrition is insufficient to meet the Millennium Development Goal 1c of reducing by one-half, the number of underweight children by 2015. The persistence of relatively high levels of malnutrition even in middle and higher income economies in the region points to existence of particular constraints that are slowing progress in many countries the region. In Egypt, Morocco, Djibouti and Yemen, it is estimated that is 7 percent of the existing annual economic losses to GDP due to malnutrition24,25. Vitamin and mineral deficiencies cost Egypt, Morocco and Syria a total of $1 billion annually24,25. The economic costs of poor nutrition are borne at two levels. Poor nutrition imposes medical and non- medical costs of illness that result from the increased vulnerability to complications during childbirth, infectious diseases, and chronic diseases. Indirect costs include the loss of labor productivity from the inability of malnourished individuals to meet their full cognitive and physical potential during child development and the resulting losses in time and wages from related death, disability, and disease. Many estimates of the burden of malnutrition are conservative and cannot fully capture all the relevant costs. Individuals could potentially lose more than 10 percent of their potential lifetime earnings as a result of malnutrition and economies can lose 2-3 percent of their GDP3. This represents a potential US$55 billion in lost GDP for the entire MENA region25. By comparison, the total cost of scaling up all ten interventions in the five countries (Djibouti, Egypt, Iraq, Morocco, and Yemen) is estimated at US$651 million, which is just over 1 percent of the total GDP loss. More analyses will be needed to examine the financial impact of the rising prevalence of nutrition-related chronic diseases across the MENA region. Egypt, for example, is expected to lose about $1.26 billion in GDP between 2006 and 2015 because of its high rates of coronary heart disease, stroke and diabetes19. These estimates only hint at the high costs that the MENA region is already paying as a result of the poor nutritional status of its children. As will be discussed in Chapter 3, below, treating chronic noncommunicable diseases may require higher cost health system resources such as higher cost of hospitalization, and will require appropriate interventions to reduce risk factors such as obesity. Whether for addressing undernutrition or overnutrition, investing in proper nutrition interventions now will have the potential to reap high returns that would strengthen the future economic and social prospects of the affected individuals as well as their family and community. 41 Box 2: National Nutrition Strategies and Policies in MENA A number of countries in the MENA region have recognized the urgency of the situation and have initiated policies to address both under- and over-nutrition. In 2007 experts from the Egypt’s Ministry of Health, National Research Council, and international organizations working in Egypt collaborated to develop a ten year National Food and Nutrition Policy and Strategy. The strategy has the goal of “guaranteeing universal availability and accessibility to high quality, safe food and promoting healthy dietary practices for the prevention and control of nutrition disorders�. It also recognizes the importance of monitoring and evaluation and is striving to develop a national nutrition surveillance system. More recently, an inter-ministerial committee on nutrition has been established and is currently chaired by Egypt’s Minister of Health. In 2009 Yemen, the Government developed its National Nutrition Strategy, which aims to reduce morbidity and mortality of Yemeni people due to malnutrition so that they can sustain their healthy life and contribute to socio-economic development of the country. The strategy will enhance nutritional interventions along the ten pillars consistent with the ten interventions recommended in this Report. These pillars focus on cost-effective interventions aimed at control of child and maternal under-nutrition, low birth weight, and micro-nutrients deficiency such as iron, vitamin A, iodine, and zinc. Most programs are supported by external assistance, which have so far focused on treatment of acute malnutrition and complementary feeding programs, including improving Infant and Young Child Feeding and the establishment of Therapeutic Feeding Centers and Outpatient Therapeutic Program Centers, respectively, at each governorate and district levels. In 2008, Djibouti developed its national nutrition strategy in collaboration with international organizations. The strategy aims to contribute to the improvement of the nutritional status of vulnerable groups, including children, women at the age of reproduction and extremely poor people. The National Nutrition Program also includes an integrated action plan which is being implemented through contributions from development partners including The World Bank, UNICEF and WHO. Morocco will be preparing its national nutrition strategy in 2010-2011, and also has plans to institute a National Alliance for Nutrition, which will build on the positive aspects of its ongoing fortification program. III. Stopping the Silent Spread of HIV/AIDS Epidemic The MENA Region has been fortunate in that HIV prevalence has remained very low. The recently published study on HIV epidemiology in the MENA region (Abu-Raddad, Akala, Semini, Riedner, Wilson, & Tawil, 2010) confirms that most MENA countries have a low HIV prevalence and no evidence exists yet for a major HIV epidemic in the general population, with the exception of Djibouti which stands out from the rest of the MENA region as having a generalized HIV epidemic. However, the total number of AIDS deaths has increased almost six-fold since the early 1990s, and half of new HIV infections are among young people ages 15 to 24, the period when sexual activity usually begins. Two main patterns of transmission describe HIV epidemiology in most of the MENA countries: 42  A pattern of exogenous HIV exposures among nationals who contract HIV outside their country and then transmit the virus to their sexual partners on their return to their home country.  A pattern of concentrated HIV epidemic among priority populations. A concentrated epidemic is defined as HIV prevalence that consistently exceeds 5% in at least one priority population. Priority populations comprise injecting drug users (IDUs), men who have sex with men (MSM), and female sex workers (FSWs). All MENA countries have populations in which concentrated epidemics have the potential to occur. The general epidemiological pattern in MENA countries points toward growing epidemics in “priority populations�, who have the highest probability of being exposed to HIV infection. “Bridging populations� are groups at intermediate risk of exposure to HIV, who provide links between the high-risk priority populations and the low-risk general population. Bridging populations include groups such as truck drivers, military personnel, sailors, and sexual partners of high risk population. A sizable fraction of MENA populations belong to this group of population, but very little critical information about this group is known, such as HIV prevalence rates, as well as prevalence rates of other Sexually Transmitted Infections; sexual risk behavior measures; and drug injecting practices. Where data are available, evidence suggests considerable levels of sexually risky behavior among the bridging populations – mostly youths – indicating the high potential that HIV could spread through this group into the general population. AIDS response in MENA remains relatively weak in comparison to global levels. With just 14% of people in need of treatment receiving antiretroviral drugs in 2008, treatment coverage rate in the Region was less than half the global average for low- and middle-income countries. The pace of service expansion is also slower in MENA than in other regions: while global anti-retroviral coverage increased more than fourfold between 2004 and 2008, a more modest expansion was reported in MENA, with coverage rising from 11% to 14% in the same four-year period. MENA also stands as the region where knowledge of the epidemic continues to be very limited among the population. Overall, this reflects a level of complacency due to the low prevalence level in the general population, and the concentration of the epidemic among the high risk groups who are in the marginalized and stigmatized group. This complacency is dangerous. MENA countries will urgently need to develop robust surveillance systems to monitor HIV spread among priority populations. Effective and repeated surveillance of priority populations across MENA will be critical for preventing the spread of HIV beyond this group. This surveillance strategy offers a window of opportunity for targeted prevention at an early stage of an epidemic, when halting new infections among priority populations would be much less costly than having to bear the cost of the treatment and care in the later stages of massive epidemics among the general population. If HIV were to spread to the general population, much of the achievements to date in improving the health outcomes of the population would be reversed, and the cost to the economy could be substantial (Jenkins & Robalino, 2003). 43 Chapter 3. Emerging Challenges of Health Transition I. Consequences of Epidemiologic and Demographic Transition Many countries in the MENA 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 3 births per women in 2006. Concurrent expansion in access to contraceptive services, improvements in girls’ education attainment levels and an increase in the age of marriage have contributed to the reductions in family size (Assad & Roudi-Fahimi, 2007). Nevertheless, MENA region was a relative latecomer to demographic transition, and the regional average Total Fertility Rate (TFR, number of births per woman) of 3 remains significantly above that of other developing regions at comparable income levels. By comparison, the developing regions of East Asia and Latin America have average Total Fertility Rates of just over 2. The rapid decline in child mortality rates and relatively slower decline in fertility rates across the region has led to a rapid population growth rate as well as one of the fastest growth in the proportion of 15 to 24 year olds in the total population. As a consequence, youth form the majority of the population in MENA: with about two thirds of the region’s population below the age of 24, MENA is facing an unprecedented “youth bulge�. The current youth bulge creates a demographic window of opportunity in which economies can benefit from a majority of individuals entering their productive peak, while the share of the population that is very young and the elderly remains relatively small. The increase in the labor supply creates possibilities for enhanced growth if they are also coupled with increased productivity, higher savings, consumption, income tax, and investment from this group (The World Bank, 2007). The large size of young population also helps to keep the demand and cost for healthcare low, as this is among the healthiest age group in any country. As the population ages, this window of opportunity will close. The countries in the MENA are at different stages of demographic transition. For most MENA countries, the demographic window of opportunity will remain open for the next decade or so. Among the countries in more advanced stages of demographic transition, the youth bulge is more pronounced: Iran, Algeria and Tunisia, and Lebanon fall within this group. These countries will face a “middle-age bulge� in the coming decade (see Annex 3: Population Pyramids for MENA Countries, 2009 and 2030) and these countries are already experiencing the effects of epidemiologic transition. Yemen, Iraq and the Palestinian Territories, which continue to show high fertility rates and high population growth rates, will likely extend the demographic window of opportunity for a longer period. Yet even in these countries, the effects of the growing share of the diseases of advanced demographic transition such as noncommunicable diseases are rising. In the labor-receiving Gulf Cooperation Council (GCC) countries, international migration plays an important role, with large numbers of expatriate workers migrate to these states for work. As most migrants are predominantly working age male population, their presence mitigates the effects of ageing among the national population. Figure 13, below, illustrates the changing demographic profile of the low and middle income countries of the region. Saudi Arabia is included as a reference for GCC countries. 44 Figure 13: Demographic transition – change in the size of youth (15-24 year olds) and middle-age (45-64 year old) cohorts between 2009 and 2035, MENA countries Percent change in the size of youth cohort (15-24 Percentage change in the size of middle age population (45-64 year olds) between 2009 and 2030 year olds) between 2009-2030 Iran -32.0 Iran 113.0 Algeria -23.5 Algeria 114.5 Tunisia -22.1 Tunisia 86.4 Morocco -7.4 Morocco 78.0 Lebanon -0.5 Lebanon 146.5 Syria 2.5 Syria 126.9 Djibouti 20.1 Djibouti 141.4 Jordan 22.6 Jordan 123.5 Egypt 25.7 Egypt 78.9 Libya 27.3 Libya 157.4 Palestinian Terr. 37.0 Palestinian Territories 145.1 Iraq 38.5 Iraq 173.0 Saudi Arabia 39.8 Saudi Arabia 163.2 Yemen 50.2 Yemen 131.0 Source: Calculated using data from U.S. Census Bureau, Population Division, updated in August, 2009. 45 The Global Burden of Disease Study indicates lists heart diseases as the leading cause of death in the MENA region, followed by low birth-weight, birth trauma, and road traffic injuries (see Table 5). Table 5: Leading Causes of Death in MENA and Global Regions, ca 2001 Middle East High-Income Low- and Middle- Rank & North Africa World Countries Income Countries 1 Heart Disease Low birth-weight, Heart Disease Low birth-weight, prematurity and prematurity and birth trauma birth trauma 2 Low birth-weight, Pneumonia, Stroke Pneumonia, prematurity and birth bronchitis, and flu bronchitis, and flu trauma 3 Road Traffic Injuries Heart Disease Depression Heart Disease 4 Pneumonia, bronchitis, Stroke Alzheimer’s and HIV/AIDS and flu other dementias 5 Diarrhea HIV/AIDS Trachea, Bronchus Stroke and Lung cancer 6 Depression Diarrhea Hearing loss, adult Diarrhea onset 7 Birth defects Depression Chronic lung disease Depression 8 Stroke Malaria Diabetes Malaria 9 Vision disorders, age- Chronic lung disease Alcohol use Tuberculosis related disorders 10 Cataracts Tuberculosis Arthritis Chronic lung disease Source: (Mathers, Lopez, & Murray, 2006) The Global Burden of Disease estimation by Mathers and Loncar (Mathers & Loncar, 2006) estimated the changes in the leading causes of deaths for different regions of the world between 2002 and 2030. Figure 14, below, summarizes the results by the three broad categories of diseases for the MENA region: Noncommunicable Diseases (NCDs) are estimated to account for 65 percent of all deaths in the MENA Region in 2002, and by 2030 NCD deaths are expected to nearly double and will represent 77 percent of total deaths. By contrast, deaths attributable to communicable, maternal, perinatal and nutrition conditions are projected to decrease from 24 to 12 percent of total deaths over the same period. 46 Figure 14: Estimated Number of Deaths and Percentage of Total Deaths, by Broad Causes in MENA Region, 2002 and 2030 2,500 100% Injuries Communicable, 90% 2,000 maternal, perinatal & Number of Deaths in 1,000 80% nutritional Percent of total deaths conditions 70% 1,500 60% Noncommunicable diseases Noncommunicable 50% 1,000 diseases 40% 30% Communicable, 500 20% maternal, perinatal Injuries 10% & nutritional conditions 0 0% 2002 2030 2002 2030 Source: (Mathers & Loncar, 2006) II. Road Traffic Injuries A. Burden of Road Traffic Injuries While the countries within the MENA region continue to benefit from globalization and their economies shift from low and middle income to high income, the burden placed on their health systems as a result of road traffic injuries is set to substantially increase if current trends continue. Deaths and disabilities due to injuries pose a serious public health problem in the Region, and some of the highest mortality rates in the region occur in low- and middle-income countries, respectively at 9% and 11.5% of total deaths. The overall mortality rate of 59.75 per 100,000 due to unintentional injuries in the MENA region is considerably higher than the corresponding rate in more developed countries of 34.5 deaths per 100,000. Fatalities due to Road Traffic Injuries. The Global Burden of Disease Study identified RTI as the third leading cause of disease burden in the MENA region which is the highest such ranking among the global regions. Most countries in the MENA region have traffic death rates above the global averages at comparable income levels. These are evident from Figure 15 and Figure 16, below. 47 Figure 15: Road Traffic Death Rates per 100,000 Population in High Income MENA Countries Road Traffic death rate (per 100,000 population) 40 35 Deaths per 100,000 30 25 20 15 10 5 0 High Kuwait Bahrain Oman Qatar Saudi United Income Arabia Arab Average Emirates Figure 16: Road Traffic Death Rates per 100,000 Population in Low and Middle Income MENA Countries Road Traffic death rate (per 100,000 population) 45 40 Deaths per 100,000 35 30 25 20 15 10 5 0 Figure 17 shows road traffic injury fatalities disaggregated by age and sex (World Health Organization, 2008a). The highest proportion of RTI fatalities occurred in the 15-29 48 age group followed by the 30-44 age group. This has important implications particularly because those two age groups together account for 40% of the entire population of MENA. This trend is also evident when the number of DALYs lost to RTI is considered (36 percent of all DALYs lost occurred in the 15-29 age group, followed by 21 percent in the 30-44 age group). Sex-specific mortality rates due to RTI in the region highlight the inequalities between genders, with the male rate over three times the female fatality rates. A quarter of of all deaths resulting from RTI occurred among males in the 15-29 age group. Disaggregating the morbidity data by sex and age reveals that the largest proportion of all DALYs lost to RTI also occurred amongst males (76 percent of all DALYs lost to RTI) and more specifically within the 15-29 year age group (30 percent of all DALYs lost to RTI). Figure 17: Proportion of all Road Traffic Injury Fatalities in the MENA region, by sex and age Source: World Health Organization. The global burden of disease: 2004 update. Geneva, World Health Organization, 2008. Available at http://www.who.int/evidence/bod Table 6 shows the level of road traffic fatalities and the categories of road users. With the exception of the Palestinian Territories, all the countries in the region are significantly above the global averages at the comparable levels of income groups. Between 15 – 33 percent of total road fatalities are pedestrians. Studies conducted in other developing regions have shown that pedestrians tend to come from lower income groups, who represent an especially vulnerable population. Additional research will be needed in the MENA region to demonstrate this important correlation, and they point to another example in which lack of information and awareness exposes the vulnerable groups to higher risks of injuries. 49 Table 6: Percentage of Fatal Road Traffic Injuries by Road User Type in MENA Countries in 2007 Road Traffic Deaths Road User Deaths (%) Motorized Four- Road Traffic wheelers death rate (Drivers/ Country (per 100,000) Passengers) Motorcyclists Bicyclists Pedestrians High Income Group (GCC) Kuwait 16.9 .. .. .. .. Bahrain 12.1 59.4 5.5 6.6 28.6 Oman 21.3 .. .. .. .. Qatar 23.7 69 4 27 .. Saudi Arabia 29 .. .. .. .. United Arab Emirates 37.1 70 1.5 .. 28.5 Middle Income Group Algeria .. .. .. .. .. Djibouti .. .. .. .. .. Egypt 41.6 47.5 0.1 1.9 20.1 Iran 35.8 44.9 11.4 .. 33.3 Iraq 38.1 .. .. .. .. Jordan 34.2 75.2 0.1 .. 24.7 Lebanon 28.5 .. .. .. .. Libya 40.5 60 5 15 Morocco 28.3 45.7 16.3 7.1 27.9 Palestinian Territory 4.9 .. .. .. .. Syria 32.9 .. .. .. .. Tunisia 34.5 50.8 14.4 2.6 32 Low Income Group Yemen 29.3 .. .. .. .. Global Averages World 18.8 High Income 10.3 Middle Income 19.5 Low Income 21.5 Source: National sources as reported in (World Health Organization, 2009b). 50 F. The High Cost of Doing Nothing: Potential Economic Impact of Road Traffic Accidents Economic Growth and Trends in Road Traffic Injuries. Economic growth and the resulting increasing motorization and industrialization are known to correlate with an increase of traffic crashes and the deaths associated with them. A literature review on industrialized countries suggested that road traffic fatality has an inverted U-shaped relationship to economic development: traffic fatality rates grow rapidly during the early period of development of a country, then plateau due to investments in road safety, and then start to decrease (Van Beeck, Borsboom, & Mackenbach, 2000). More recent research on developing countries suggests, however, that this presumption may not hold for developing countries, due to the fact that the rate of economic growth often outstrips the pace of improvements in the design of a developing country's infrastructure and road safety policies and programs. The combination of large number of inexperienced younger drivers on dysfunctional roads is a lethal combination. It would appear that the expected reduction in road traffic injuries is being delayed in the MENA region, partly due to the very large number of youths who tend to be the group most at risk of RTI, and the delayed introduction and implementation of effective road safety policies and programs. Projections of Road Traffic Fatalities and Disabilities in the MENA Region. Two main models of road traffic fatality projections exist: the WHO Global Burden of Disease (GBD) projections and the World Bank Traffic Fatalities and Economic Growth (TFEC). The 2004 GBD update using health data has published projections for fatalities and Disability Adjusted Life Years (DALYs) between 2008 and 2030 (Table 7). It should be noted that women are at higher risk of road traffic deaths and disabilities. The World Bank data looked at a different time period between 2000 and 2020, and used a model based on transport, population and economic data (Table 8). Both predict a substantial increase in road traffic fatalities if current policies and actions continue without improvement. A significant proportion of the burden on the health systems will be placed by those who sustain non-fatal injuries and disabilities, and disability rates are predicted to increase by 31% by 2030 (Mathers, Lopez, & Murray, 2006). It is clear that effective interventions and safety programs particularly those targeted at specific risk factors (e.g. vulnerable road users, occupational risks) need to be implemented in the region if this escalating health problem is to be prevented. It should be noted, however, that despite the large burden of road traffic injuries in the region, data from MENA is somewhat limited and inadequately measured. This paucity of data may lead to a potentially large underestimation of the true extent of mortality and morbidity associated with RTI in the region which needs to be addressed. 51 Table 7: Predicted road traffic fatalities and disabilities in MENA Region – WHO model, 2008–2030 % change Projected Totals 2008 2015 2030 2008–2030 Male 90,509 102,221 123,867 36.9 Projected Deaths Female 25,643 30,427 40,553 58.1 Total 116,152 132,648 164,420 41.6 Male 3,009,130 3,361,410 3,880,690 29.0 Projected DALYs Female 940,872 1,076,376 1,290,617 37.2 Total 3,950,002 4,437,786 5,171,307 30.9 Note. DALYs: Disability Adjusted Life Years (3% discounting, no age weighting). Source: (World Health Organization, 2008a). Available at http://www.who.int/evidence/bod Table 8: Predicted road traffic fatalities in MENA region in thousands, 1990-2020 Number of % Change Countries 1990 2000 2010 2020 2000- Surveyed 2020 Middle East & 13 41 56 73 94 68 North Africa High Income 35 123 110 95 80 -27 Countries Source: Koptis, E and Cropper M. Traffic and Economic Growth, Washington DC, World Bank, 2003 (Policy Research Working Paper no. 3035) Economic Impact of Road Traffic Injuries. Traffic injuries and deaths translate into present and future economic losses that could act as a drag on economic growth and inflict substantial changes in the composition of the labor force. According to Elvik43, there are three major components of road crash costs. The first component is the direct costs of crashes: these include any additional expenses caused by crashes and include costs of medical treatment, costs of repairing or replacing damaged vehicles, and administrative costs. The second component is the indirect costs of crashes which include the losses in output attributable to premature death and permanent impairment or temporary absence from work. The third component is the social valuation of lost quality of life, which represents the value of preventing premature death and the associated pain, grief and suffering caused by road crashes. Using this framework (Hyder, 2009) estimates the economic cost of road traffic deaths in the MENA region to be in the range of 0.9% and 2.1% of the total regional GDP. Implementing Cost-effective Interventions. MENA countries can decrease this potentially negative economic impact through relatively cost-effective interventions. 52 Simple and inexpensive interventions in the road design – such as pedestrian crossings, safety fences, turnabouts and speed bumps – have been shown to be highly effective in preventing road traffic injuries and deaths in other countries. Implementation of safety belts for automobiles and helmets for motorcycles, enforcing speed limits and prohibiting drink-driving are examples of other cost-effective strategies that can save lives. But this will require a commitment by both national leaders and the public towards effective and pro-active implementation of road safety policies and programs. G. Building institutional and management capacities for road safety Evaluation of Institutional Capacity for Road Safety in MENA Region. A review of the institutional framework in the MENA region shows that most countries have established an intersectoral agency responsible for road safety and have legislation in place related to key road safety issues: setting speed limits, prohibiting drinking and driving, and requiring the use of seatbelts for cars and helmets for motorcycles. However, few countries have comprehensive road safety laws that are well enforced (Figure 18). Figure 18: Road Safety Compliance Levels Among 17 MENA Countries, 2010 100% 2 1 % Countries, Numbers in columns 90% 1 5 3 Not available 80% 5 4 70% None (no law in 60% place) 50% 8 Low 40% 11 7 9 Moderate 30% 20% 5 High 10% 3 1 2 0% Maximum Drink-Driving Motorcycle Seatbelt Law Urban Speed Law Helmet Limit Source: (World Health Organization, 2009b) Note: Enforcement scores represents concensus based on professional opinion of respondents, on a scale of 0 to 10 where 0 is not effective and 10 is highly effective. “Low� refers to score 1 – 3, “moderate� for scores 4 – 7, and “high� for scores 8 – 10. For details, see Table 44 in Annex. Need to strengthen governance and accountability for better results. Most MENA countries have established an intersectoral institution to take the lead on road safety. However, many of these are not funded, nor have they developed a national strategy with measurable outcomes indicators (see Figure 19 and Table 45). Achieving better results on road safety will require more than enhancing the capacity of the existing institutions. It will also require substantial improvements on the existing information and surveillance system. 53 Most countries do not have injury surveillance systems that generate reliable data on road traffic crashes, injuries, and deaths. This may contribute to underreporting and discrepancies in the data. Few countries regularly collect reliable information or use them to establish targets for achieving results. Conduct of strategic research will also need to be encouraged in order to understand better the roles and contributions of different stakeholders, and clear specification of the potential benefits to be achieved. Adoption of best practices in the region through information exchange, production of shared guidelines, manuals, and the development of a regional crash, injury and death database, and a regional road safety policy research program would be valuable. Figure 19: Road Safety Institutional Commitments in 17 MENA Countries, 2007 18 16 1 Number of MENA Countries Reporting 14 5 5 8 12 Not 10 13 Available 5 8 No 6 11 4 9 7 1 Yes 2 3 0 Traffic Safety National Road Measurable Formal Road Agency Funded Safety Strategy Targets Safety Audits in National Established Budget Source: National sources as reported in (World Health Organization, 2009b). There is a need to strengthen the institutions and governance capacity for RTI prevention in the region. This will include not only enhancing capacities in the lead agency, but also targeting evidence-based training of senior policymakers and managers in the various relevant sectors, and ministry focal points and practitioners, especially in transport, justice, traffic police, and health. Creating space for civil society and private sector participation has the potential to mobilize political support on the basis of well-articulated social demands from communities that bear the burden of RTIs. H. Focus on Results in Road Safety The following actions are recommended to achieve better results in road safety: 54 Strengthening national institutional capacity and accountability  Improving nationwide traffic injury surveillance systems to better map the causes, risks, extent, and consequences of injuries; to pinpoint risks for more effective action; and to evaluate the effectiveness of those actions.  Promoting national road safety reviews as the basis for formulating policies and plans. These reviews help identify main risk groups and exposures to determine priorities, set realistic targets, allocate budgets, specify implementation responsibility, and ensure rigorous evaluation.  Designing demonstration projects. Well-designed demonstration projects can support the process of catching up with best practice in road safety performance and are an essential part of building capacity. They can provide useful benchmarks for rolling out a modern road safety program to the rest of the country with support from donors and international finance organizations. Integrating road safety in the design of road infrastructure and traffic control and management programs  Integrating road safety and transport policy. Recent research indicates that improving transportation options (for example, better walking and cycling conditions, and improved ride sharing and public transport services) can reduce car collision frequency.  Integrating road safety in all phases of planning, design, and operation of road infrastructure. At the planning stage, before project approval, strategic comparative analysis of substantial changes and new construction need to be conducted to examine the network’s safety performance. Road safety audits and safety impact analyses complement these assessments focusing on the design characteristics of a road infrastructure project. In addition, reviews of high road traffic crash concentration sections need to be undertaken to help target investments to road sections with the highest crash concentrations and/or the highest crash reduction potential.  Reducing speed limits, particularly in urban areas, and strengthening these efforts with road design, enforcement, publicity, speed cameras and appropriate penalties, to generate immediate safety benefits.  Increasing seatbelt use through enforcement and publicity campaigns, revising specifications (at least for new cars), promoting vehicle seatbelt reminder systems, and undertaking periodic surveys to monitor front and rear seatbelt usage rates.  Mitigating young driver risk through graduated licensing schemes and extended training programs. Integrating road safety in health care system responsiveness  Integrating road safety with improvements in the quality and responsiveness of emergency medical systems as part of broader health system modernization efforts to reduce fatalities and mitigate injuries. It is a concern that there is relatively limited investment currently in either road traffic injury prevention or trauma care in MENA, especially in view of the increasing burden of death and disability that these injuries are unleashing. An immense potential exist for saving lives and suffering from road traffic crashes in the MENA region. It is 55 obvious that more research is needed in this area of the world in order to have a better understanding and appreciation of the economic and social impact of road traffic deaths to support the development of appropriate road safety policies. 56 III. Meeting the Challenges of Non-communicable Diseases A. Overview Chronic Non-communicable diseases (NCDs), which include cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, account for up to 60 percent of the total deaths globally. They have already become the biggest challenge for health systems the world over, rich and poor. WHO estimates that in 2005 around 35 million people, soon to rise to 41 million in 2015, died from NCDs, not to mention those have become incapacitated at a significant loss of productivity, earnings and wealth (Obegunde, Mathers, Adam, Ortegon, & Strong, 2007). As discussed in the preceding section, NCDs are already the leading cause of death and disability in the MENA region. The challenge is enormous: a relatively modest global goal of 2 percent reduction per year in NCD-related deaths, as advocated by WHO, would require a major overhaul in the way most health systems are designed, structured, led, organized, funded, and their services delivered ( (World Health Organization, 2005), (World Health Organization, 2008b)). On the other hand, failure to do so could prove to be more costly. Not only will the additional health care costs be significantly higher (estimated at some 2- 4 percentage point of GDP for MENA - see Figure 20) but also because NCDs typically strike the young adults at the peak of their productive years and as such results in considerable aggregate loss of productivity and societal wealth often estimated at several times direct health care costs (Suhrcke, Nugent, Stuckler, & Rocco, 2006). Figure 20: Potential Changes in Total Health Expenditure due to NCDs as Percent of GDP 1 4 .0 1 2 .0 1 0 .0 8 .0 6 .0 4 .0 2 .0 0 .0 E AP EC A LAC M EN A S AR 2000 2 0 3 0 , a g in g o n l y 2 0 3 0 , a g in g a n d a g e - s p e c if ic in c r e a s e s Source: (Adeyi, Smith, & Robles, 2007) 57 As discussed in the previous section, in the MENA region NCDs were estimated to account for 65 percent of all deaths in 2002, and by 2030 NCD-related deaths are expected to nearly double to represent 77 percent of total deaths (Mathers & Loncar, 2006). About 50 percent of these deaths will be among people younger than 70 years of age, who will have accumulated considerable NCD who in their early adulthood did not benefit from effective public health programs and preventive care aimed at improving diet and physical activity or reducing alcohol and tobacco consumption, or they may not have had access to timely and adequate healthcare once they became sick. The existing global evidence corroborates this prediction: at present, age standardized death rates for NCDs in middle- and low-income countries are 50 percent higher than in high-income countries. This means that after controlling for ageing in high income countries, 50 percent more people in the developing world die of NCDs than in developed countries, simply because they acquire them at a higher rate and die from it more frequently as a result of lower access to quality healthcare. This is further corroborated by comparing the age-weighted Disability Adjusted Life Years (DALYs) due to NCDs among MENA countries, selected Middle Income countries, and Japan. Japan has been chosen here as a country with one of the oldest population in the world, and yet also with one of the lowest age-adjusted DALYs. This means that after adjusting for age structure, Japan has the lowest loss in terms of premature deaths and disability adjusted-life years, and represents the current “gold standard� in terms of how far a country could reduce the burden of diseases due to NCDs. Figure 21, below, compares the straightforward number of deaths per 100,000 population attributable to NCDs for MENA countries, selected comparator middle income countries, and Japan. As can be seen, Japan has the highest death rates due to NCDs due to the very high proportion of elderly who carry a larger share of NCD disease burden. However, when age-adjusted DALYs are used to compare performance across countries, MENA countries are generally doing worse than the comparator countries (i.e. have a higher rate of age-adjusted DALYs), and in comparison to Japan most MENA countries are more than twice the rate of DALYs. 58 Figure 21: Deaths due to NCDs per 100,000 in MENA and Comparator Countries Deaths due to NCDs per 100,000 700 600 500 400 300 200 100 0 Figure 22: Age-adjusted DALY per 100,000 attributable to Noncommunicable Diseases in MENA and Comparator Countries Age-adjusted DALY per 100,000 attributable to Non-communicable Diseases, MENA and Comparator Countries 20,000 15,000 10,000 5,000 0 Turkey Morocco Saudi Arabia Lebanon Egypt Algeria Yemen Iraq Syria Tunisia Mexico Iran, IR Bahrain UAE Indonesia Libyan AJ Jordan Kuwait Costa Rica Oman Malaysia Djibouti Japan Qatar Source: World Health Organization -Department of Measurement and Health Information, compiled from the Global Burden of Diseases statistical database available on www.who.int/evidence/bod. Notes: 1. Data for the Palestinian Territories were not available. 59 B. Addressing the NCD Challenge: Managing the Risk Factors Is it possible to bend the curve and change the trend? Fortunately, yes. About 80 percent of premature deaths due to cardiovascular diseases (CVDs) and diabetes could be prevented through efficacious population health and individual counseling and care interventions which, if implemented effectively, could result in substantial reduction in morbidity and deaths, and gains in economic welfare (see EU, 2000 and WHO, 2005). In the MENA region, the risk factors mentioned above account for the majority of the disease burden due to NCDs, much of which can either be prevented or clinically managed in a cost effective manner (See XX for details). For instance, it is estimated that if Egypt, the MENA country with the highest burden of cardiovascular diseases could decrease its share of NCD related deaths by 2 percent by the year 2015, its life expectancy will by then be 2 years higher, 72.1 vs. 70.1 years compared to 67.7 years in 2005 (Obegunde, Mathers, Adam, Ortegon, & Strong, 2007). Could it be done in a fiscally and financially sustainable manner? The answer is once again yes, if the countries can act in a proactive manner by adopting evidence-based inter- sectoral strategies of primary prevention to curb smoking and obesity and encourage physically active living. For instance, reduction in salt intake and tobacco control alone could avert 14 million deaths in the 23 countries around the globe that account for 80 percent of the NCD burden at a modest cost of $0.40 per person per year. Scaling it up with aspirin and cholesterol lowering drugs could avert 18 million deaths in these countries over a period of ten years and at a cost of $1.10 per person per year (Horton R. , 2007). The implementation of preventive policies and interventions will potentially avert direct healthcare costs in the future years as the present cohort of youths in the MENA region enter middle-age years. There are also potential savings as a result of reduction in absenteeism and gain in labor productivity due to healthier workforce. A reduction of 2 percent in NCD related deaths in Egypt is expected to bring about savings in the amount of about 9 percent of the projected cumulative GDP loss of 1.26 billion due to treatment and productivity costs in the process (Obegunde, Mathers, Adam, Ortegon, & Strong, 2007). As a corollary, and to emphasize the importance of reducing economic costs due to reduced labor, a recent study on Egypt showed that chronic health conditions may cause up to 6 percent loss in employment and 19 percent reduction in labor supply. The probability of being employed is 25 percentage points lower among people reporting chronic health condition (the average probability is about 50 percent) and the amount of working time is reduced by 22 hours per week (out of about 40), especially among the less educated and the older population (Rocco, 2010). Thus, NCDs could disproportionately affect the welfare of the poor and more vulnerable segments of the population. Tobacco and Obesity as Major Risk Factors Two risk factors, tobacco use and obesity, the so-called modern risks, along with road accidents detailed in the previous section Figure 23deserve special emphasis. Figure 23 describes the health transition over time as country undergoes economic development. These two risk factors account for a significant share of disability and premature mortality. There are effective policy interventions known to curb tobacco use and promote healthy diet, but much of the intervention lies outside of the healthcare system. Therefore, addressing these risk factors effectively will require inter-sectoral partnership, advocacy and action. 60 Figure 23 : Transition over time from Traditional to Modern Health Risks Source: (World Health Organization, 2009b) According to Centers for Disease Control and Prevention (CDC) of the Unite States, 80 percent of diabetes, heart disease and stroke could, in principle, be eliminated by reducing smoking and obesity. On the other hand, lack of effective primary prevention leading to higher prevalence of smoking and obesity could result in significantly higher health care costs. A review of global trends suggests that the increase in morbidity due to these risk factors may account for a much larger share of increase in costs than the effects of aging alone (Sturm, 2002). The United States spends almost twice per capita in healthcare than the average per capita spending in Western Europe. One study using 2004 data for the US and ten Western European countries estimated that 85 percent of the higher average per capita health spending in the US could be explained by the higher obesity and smoking rates in adults over fifty years in the US. As a consequence of the higher rates of risk factors, higher proportions of US population are being put under treatment for high blood pressure, high cholesterol and diabetes which add to the cost of care (Thorpe, Howard, & Galactionova, 2007). The US also lags behind Europe significantly in reducing mortality from preventable causes of death that could have been addressed through primary prevention (Nolte & McKee, 2008). These data provide evidence that the prevalence, morbidity and mortality due to NCD can be reduced in a cost-effective manner through primary prevention. 61 Table 9: Comparisons between US and Western Europe on health expenditures, obesity and smoking rates, 2004 US Western Europe Average per capita total health expenditure $6,037 $3,268 ($PPP) Obesity Rates in adults over 50 years 53 33 Smoking Rates in adults over 50 years 43 17 (European Commission, 2004) Smoking Smoking is the leading risk factor in the MENA region among adults accounting for a very large disability and death. A majority of MENA countries have high prevalence of daily smokers above 20 percent of the population, and they are significantly higher than comparator middle income countries such as Mexico and Costa Rica, and some exceed those of Indonesia and Turkey, which are known to have some of the highest rates of smoking in the world (see Figure 24). Figure 24: Age-adjusted Prevalence of Daily Smokers per 100 in MENA and Comparator Countries, 2008 Age-adjusted prevalence of daily smokers, per 100 70 prevalence of daily smokers per 100 60 50 40 30 20 10 N/A N/A 0 adult males adult females 62 The habit of smoking often begins in early teenage years, and once started it becomes very difficult to quit. Teenage smoking rates in the MENA region are also high, and it is especially worrisome that smoking is becoming popular among young teenage girls across the region, but especially countries such as Lebanon, Libya and Tunisia (Figure 25). The very low cost of cigarettes throughout the Region encourages smoking to be taken up, even by the youths (see Figure 26). Figure 25: Smoking Prevalence among Youth Aged 13-15 in MENA and Comparator Countries, 2008 Smoking prevalance among youth age 13-15, in MENA 2008 70 60 Prevalance rate per 100 50 40 30 20 10 0 Male Female 63 Figure 26: Average Price per Pack of 20 Cigarettes in MENA Countries Source: (World Health Organization, 2009c) Most countries in the MENA region have made important progress in ratifying the Framework Convention on Tobacco Control (FCTC) and passing the relevant legislation. Subsequently the progress in MENA leaves much room for improvement, especially compared with the rest of the world. The MENA region is particularly lagging with respect to (a) promoting smoke free environment, (b) enforcement of warnings on tobacco products about the deleterious health effects, and (c) taxation (Figure 27). 64 Figure 27: The state of selected tobacco control policies in MENA, 2008 100% 1 3 90% 4 3 80% 7 4 No data/data not 9 (Number of countries inside bars) 70% available 13 No policy Proportion of countries 60% 7 10 Minimal policies 50% 5 40% Moderate 10 policies 5 30% Complete 5 3 policies 20% 8 5 10% 4 3 2 2 0% Monitor Smoke-free Cessation Health Advvertising Taxation environments programmes warnings bans Source: (World Health Organization, 2009c) Introduction or increase in excise and other taxes on tobacco products is especially a viable policy option, not only because it is the most cost-effective intervention that exists to curb smoking, but also because the additional revenues thus collected could be earmarked for population-based health programs. This will require a close partnership between Ministries of Finance and Health. According to our estimates, in Egypt alone, a fully comprehensive and effective tobacco control program could prevent about 11 percent of premature excess deaths a year, amounting to 621,960 lives saved over a period of 20 years. Examples exist around the world of successful tobacco prevention programs, with evidence of impact on reducing the burden of NCDs. In Australia, for example, a leader in effectively introducing and enforcing comprehensive and intersectoral policies, rates of lung cancer declined and deaths from coronary heart disease decreased by 59 percent among men and 55 percent among women between 1980 and 2000 (Chapman S. Reducing tobacco consumption. NSW Public Health Bulletin, 2003,14:46–48). A comprehensive set of policies would include pricing, pack warnings, advertising bans, national tobacco control campaigns, quit-line services for smokers, extensive advocacy programs, smoking bans, adoption of smoke-free homes and litigation by smokers and passive smokers against tobacco companies . One of the most effective control measures is price increase through taxation: while its elasticity may vary from one country to another, on average, an increase of 10 percent is expected to result in a decline of 3–5 percent in consumption (Chaloupka F, 65 Warner W. The economics of smoking. In: Culyer A, Newhouse J, eds. Handbook of health economics. Amsterdam, Elsevier Science, 2000, Volume 18: 1539–1627). A country closer to MENA, Turkey, has recently been able to become a front-runner in adopting comprehensive and intersectoral measures under the leadership of the Ministry of Health (see Box 3). Box 3: Tobacco control in Turkey Turkey is one of the top 10 consuming countries, with 20 million smokers spending about 20 billion dollars a year on tobacco products. Nearly half of the men and one in every six women smoke. Smoking has recently become more popular among women and adolescents, and young people start to smoke at around 13 years of age. An 80% increase in smoking rates during the last two decades of the previous century as a result of opening its market to foreign brands resulted in a subsequent significant rise in lung cancer and NCDs. In Turkey, more than 100 000 people die every year as a consequence of smoking (a quarter of all deaths), a number that is estimated to rise to 240 000 by 2030. More recently Turkey has made a major effort to stem the tobacco epidemic. This is largely due to the high level of leadership and political commitment. When the first tobacco control law was enacted in 1996, banning advertising and smoking in public places, many complained that it was contrary to Turkish culture and could never be enforced. There were some setbacks to full enforcement of the smoking ban at the time, but the law not only remained unadulterated, despite many attempts by various pro-tobacco lobbyists but was strengthened in 2008. This was largely a result of Turkey’s ratification of the WHO Framework Convention on Tobacco Control in 2004, which allowed policy- makers to further pursue the issue. The commitment and leadership of the Ministry of Health has been crucial throughout. First, a special unit was established in 2006 devoted exclusively to tobacco control. Second, a National Tobacco Control Committee was created, with high-level representation of key ministries and civil-society organizations, as stipulated by the Framework Convention. Third, in 2007 the Prime Minister launched the first five-year National Tobacco Control Programme and Action Plan, prepared by the National Tobacco Control Committee. Fourth, the Government continually increased taxation on tobacco products to reach a compound tax rate of 73–87%, depending on the brand, one of the highest rates in the world. Finally, the amended law in 2008 expanded smoke-free environments to cover all indoor areas. This includes the hospitality and tourism sector – a major source of foreign exchange – which was given an eighteen-month transition period. When the law entered into force for this sector on 19 July 2009, Turkey became the sixth country globally with national smoke-free laws containing no exemptions: no provisions for designated smoking rooms in public places. The new law and the political commitment that supports it are an example of best practice from which other countries can learn. The law was judiciously rendered free of loopholes or ambiguities that could be abused. For instance, the previous law required 90 minutes of air time for information, education and communication for tobacco control on broadcast mass media, but the amended law specifies that 30 of the 90 minutes must be during prime time, for greater exposure to achieve the objective of creating an antismoking culture among 90% of the population by 2012. In addition, tobacco products may not be displayed in television programmes, films, music videos and advertisements,and all smoking scenes are blurred. Enforcement is taken very seriously, as all broadcast mass media stations are required to use a set of messages approved by the Ministry of Health for information, education and communication, and to prepare a compact disc of their advertisements every month for review by the Higher Radio and Television Council. This is a major undertaking in a country in which the penetration of broadcast mass media is almost universal, with some 1400 national, regional and local television and radio stations. Despite the initial objections on cultural grounds, recent polls show that more than 85% of the population now favours the smoke-free legislation. Attitudes and awareness have changed to such an 66 extent that the Prime Minister has publicly mentioned the fight against tobaccoin relation to the fight against terrorism. Sources: Bilir N, Cakir B, Dagli, E, Erguder T, Onder,Z. (2009). Tobacco Control in Turkey. World Health Organization, Regional Office for Europe, Copenhagen, Denmark, 2009. World Health Organization (2009). The European Health Report 2009: health and health systems. World Health Organization, Regional Office for Europe, Copenhagen, Denmark, 2009. Courtesy of WHO Regional Office for Europe (permission to reproduce pending) Obesity Kuwait, Jordan, Egypt and the United Arab Emirates have among the highest obesity rates in the world, as measured by percentage of population with Body Mass Index (BMI) of 30 kg/m2 or more (Figure 28). Often perceived as a risk factor more prevalent in wealthier populations and individuals, obesity is much more pervasive, affecting equally the poor and the rich, with a disproportionate frequency in poorer populations in low- and middle- income countries. It is so mainly as a result of the poor not being able to afford more costly foods such as fruits, vegetables and whole-grain cereals, as well as their lack of leisure time and opportunities for exercise, especially for women (Monteiro et al 2004). These international trends point to the importance of designing policies aimed at reducing health inequities associated with obesity, which will likely be correlated with poverty and gender inequalities. 67 Figure 28: Obesity Rates (BMI > 30 kg/m2) in MENA Countries and selected Benchmark Countries, 2006 50 % population with BMI > 30kg/m2 40 30 20 10 0 Japan Yemen Qatar Mexico Malaysia Costa Rica Bahrain Iran, IR Jordan Oman Kuwait Indonesia Turkey Lebanon UAE Syria Morocco Egypt Algeria Djibouti Tunisia Libya AR Saudi Arabia Males Females Source: WHO Infobase data, accessed May 2010. The combination of poor diet and lack of or insufficient physical activity leading to obesity and consequently to higher prevalence of diabetes, hypertension, heart disease, stroke, and many other chronic diseases, especially among poorer children and women is a “time bomb� in MENA with potentially huge consequences on future health spending, and labor productivity as the youth bulge gives way to middle age bulge, requiring therefore urgent and multi-pronged intersectoral action. 68 Box 4: Obesity: is it a private or public “bad�? Most policy makers and indeed health professionals regard obesity, the accumulation of excess body weight, as an individual problem requiring behavioral change. Granted, obesity is a consequence of excess energy intake and/or reduced energy output over time and as such, could, in principle, be prevented or “treated� by either reducing intake of calorie through diet and/or increasing output by physical activity. In reality, however, individualized approaches to obesity prevention and treatment are likely to fail if they are not accompanied by societal and community interventions aiming at the root cause of obesity, the built “obesogenic� social, economic and physical environment, in which the individual live. First, obesity, and thus cardiovascular diseases and diabetes in adulthood, are more common in people who suffered from intrauterine growth retardation, undernutrition and stunting in childhood, conditions over which individuals would have little control. Indeed the “dual� burden of adult (mostly female) obesity and underweight children in the same household is increasingly recognized as a leading transitional cause of the NCD burden in the developing world, especially among the poor, and thus of the widening inequalities in health. Second, urbanization has deeply transformed the patterns of daily living through increased mechanization and automation by limiting vigorous physical activities such as farming and walking, and thus reducing significantly the amount of energy we need. It has also increased availability and affordability of energy-dense food and access to readily-made food outlets, especially for the poor who typically spend 60% of their income on food. In 2001 in the US, only 16% of children walked or biked to school, down from 42% in 1969. Nowadays, a typical US teenager spends about 30 hours watching TV or playing computer games while often consuming snacks the existence of which is persistently reminded to him/her through TV ads. Recognizing the severity of the problem, and the potential role of the public sector in modulating the built environment, many countries are increasingly adopting “healthy� multi- sectoral policies to counter the trend. These include interventions that address food production (packaging information) and marketing (e.g., TV ads, school cafeterias, taxation of food with high sugar and salt content); transportation (e.g. sidewalks, bicycle lanes and parking facilities, more accessible public transport); public safety (e.g. for pedestrians or for walking and outdoor activities); targeted information, education and communication (e.g., early childhood development, pre- and post-natal maternal counseling, food and nutrition curriculum in schools); and financial (e.g., food vouchers, cash transfers, subsidies for public transportation, etc) and non financial incentives in schools and workplaces and communities (e.g., sport facilities in workplaces and schools, healthy food distribution at schools, parks, sidewalks, bicycle lanes, etc). Compiled from: Caballero B: The Global Epidemic of Obesity: An Overview. Epidemiologic Review, 2007;29:1-5. C. Next Steps: Strategies for NCD Prevention, Control and Case Management Curbing the epidemic of NCDs will require a multi-faceted approach that go beyond the traditional boundaries of the health sector, and call for the use of a wider array of policy instruments and approaches and involve a broader set of stakeholders.  Promoting lifestyle changes to reduce obesity, smoking and other related risk factors that contribute to NCDs;  Reorienting health services and its physical, human and financial resource base to design and implement healthcare models conducive to health promotion and 69 disease prevention, and continuity of care for patients who suffer from chronic NCDs; and  Introducing continuous monitoring and evaluation of “the health of the nation� to measure the effectiveness of policies, strategies and interventions, and to redefine targeted groups, and accelerate, adjust or change policies as necessary based on evaluation of impact on the ground. With respect to NCD prevention, WHO recommends that “settings where children gather should be free from all forms of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt. Such settings include, but are not limited to, nurseries, schools, school grounds, and pre-school centres, playgrounds, family and child clinics and paediatric services and during sporting and cultural activities that are held on these premises.� Mindful of the importance of monitoring and implementation of such policies, WHO also recommends that the proposed policy framework include enforcement mechanisms, “…clear definitions of sanctions and [could include] a system for reporting complaints� and “a system to evaluate the impact and effectiveness of the policy… using clearly defined indicators� (World Health Organization, 2010a). In a recent international review, the OECD developed a taxonomy combining the classification of health determinants and the different types of preventive interventions and their implications on individual choice. Table 10, below, identifies the most common set of preventive interventions, which range from the less intrusive to more coercive interventions. For example, the less intrusive interventions involve widening of consumer choice by pricing and rendering of available alternative options (e.g., conditional cash transfers for families with young children to promote healthy nutrition, creating safer environments through road safety), while a more coercive, regulatory interventions include regulations that restrict fast food advertising in children television programs to taxation on sugar containing non-alcoholic beverages and banning smoking in public places (OECD, 2008). The acceptability of these interventions and their effectiveness will vary from country to country, depending on local preferences and acceptability of these approaches. Based on the review of state of tobacco prevention and control programs in the Region, most of the MENA countries appear to have formally recognized the importance of prevention. However, the enforcement and measurement of results remain weak, and there is little evidence to date of the effectiveness of tobacco control programs. The review of policies and programs in the MENA on Smoking and Road Traffic Injuries (previous section) has also revealed shown a similar trend: that while many countries have a national strategy and framework legislation in place, monitoring of their enforcement and the actual compliance remains low. On obesity, there is even less evidence of national commitment to address this issue. What is needed is a coherent strategy on diet, physical activity and health with special emphasis on the marketing of foods and non-alcoholic beverages to children in schools, child care and educational facilities to reduce the health impacts of those with high content of saturated fats, trans-fatty acids, free sugars and salt. It is equally important to start continuous monitoring of trends in childhood obesity, especially among the poor and vulnerable population groups. There is an urgent need to call the attention of the national leaders to the risks of NCD epidemic and its potential detrimental effect on the welfare of the future generation. 70 Table 10: A Taxonomy of a Select List of Preventive Interventions and their Relevance to MENA Countries Interventions to Interventions to Interventions to widen choice or lower influence choice raise the price Interventions Areas of price of choice other than of selected to ban selected Remarks for MENA Intervention Main Actors options through pricing choice options options countries Interventions Government, Targeted social Could be linked with aiming at (Ministry of programs and subsidy reforms and influencing broader Finance, Social conditional cash well-targeted social socio- economic Affairs, NGOs) transfers to reduce programs determinants vulnerability Interventions Government, Interventions aiming Highly relevant, and aiming at school or (Ministry of at: increasing physical technically and work environments Labor, activity – school economically feasible in Education, physical education most countries. Urban Planning, curriculum; promoting Political commitment trade unions, safer roads and required. business pedestrian-friendly leaders, urban design; ensuring professional safe work environment associations) and effective occupational safety programs Interventions Government (M Subsidies to producers Regulation to Banning the use Highly relevant. aiming at food and of Agriculture, of fruits and vegetables limit advertising of trans-fatty Political feasibility may non-alcoholic Industry, Food of fast food in acids in selected need to be assessed on a beverage manufacturers children TV settings. country by country basis production, and retailers) programs distribution and retail industry 71 Interventions to Interventions to Interventions to widen choice or lower influence choice raise the price Interventions Areas of price of choice other than of selected to ban selected Remarks for MENA Intervention Main Actors options through pricing choice options options countries Health care Government Programs on Highly relevant. interventions (Min of Health, lifestyle Requires political Health counseling of commitment and insurance individuals at incentives to healthcare plans, risk, in primary providers Providers) health care settings Interventions on Government Taxation of sugar Smoking ban in Highly relevant. Either lifestyle choices (Min of Finance, containing public places already existing, but in Health, beverages; need of reinforcement Agriculture, tobacco products (smoking ban), or Industry) requires assessment of political feasibility. 72 In conjunction with these population-based NCD prevention and control programs, there will be a need to reorient the health system to promote primary prevention as well as provide effective treatment for patients who suffer from NCDs. In this context, it will also be important to:  assess the effectiveness and cost-effectiveness, and wide scale applicability and use of new pharmaceuticals and medical devices;  devise financial incentives to encourage integrated, coordinated and continuous care, including greater reliance on health professionals other than physicians, such as nurse practitioners, community nurses, case managers, and family care givers, and  make better use of the available information and communication technology (ICTs) such as electronic patient records and clinical decision support systems (CDSSs) (Busse et al, 2010). The limited available evidence from the MENA region suggests that many countries have not yet taken the steps needed to reorient the health systems towards NCDs. Some of these will be discussed in Chapter 5 “Aspiring for Better Health System Performance for Better Health in MENA�. In the developed countries, this is also an area under development and new care models are emerging as alternatives to traditional hospital-based curative care models. These new approaches include a number of Disease Management Programs and integrated care models that hold promise to offer more effective approaches in improving health outcomes of NCD patients, as well as potentially contain costs and increase patient satisfaction. What is still needed is to develop appropriate NCD case management models that are appropriate for the lower and middle income countries. The MENA Region has considerable resources and capacities that could be applied towards finding a solution appropriate to the local conditions. The time to act is now, before the NCD becomes a major epidemic in the region. The MENA countries will face new challenges on a number of fronts as a consequence of the increase in NCDs. Countries could mobilize additional resources to finance the expected rise in the cost of healthcare, the need to design and implement new strategies and interventions to reduce the burden of NCD and to treat and control the disease at the earliest stages, thereby minimizing the suffering and cost to the patient and the society. There is an opportunity to act now, while most of the population in MENA are still young and relatively healthy. This will require foresight and committed leadership at all levels of the society, and a greater understanding of the underlying causes of the risk factors in the MENA context. The rise in the prevalence of many of the risk factors can be traced to behavioral consequences of a multiplicity of causes: increased international trade (e.g., tobacco products, processed foods), migration (e.g., urbanization and sedentary lifestyle), changes in living conditions (e.g., obesogenic work and living environment) and in the production, marketing and availability of goods (e.g., processed food). The healthcare systems will also need to be reoriented to meet the new challenges presented by NCDs, including primary prevention as well as improved case management for those who have NCDs. Potential solutions are bound to be context specific and as such pose major challenges to policy makers, professionals and the population, requiring an effective partnership among all the key stakeholders. Table 12 below provides a list of “grand challenges� in chronic non- communicable diseases identified by 155 stakeholders from 50 countries, and their potential relevance to the MENA region. Table 12: Grand challenges in building partnership for better prevention and care in MENA 73 Policy Goal Challenges Health system Partnership in MENA specific remarks involvement and shared responsibility responsibility Raise public 1. Raise the political 1. Leading role in 1. Within 1. Very high priority in all awareness priority for advocacy within government/cabi MENA countries for preventive health the government, net across all raising awareness 2. Promote healthy civil society sectors about healthy lifestyle and 2. Leading role in 2. Partnership with lifestyles, improving consumption building media, consumer child nutrition, and choices through partnership within advocacy groups, road safety effective government and NGOs, civil 2. Ditto education and with civil society society, 3. Needs expanded public 3. Leading role in professional coverage especially engagement building associations, regarding diet, obesity, 3. Package partnership with schools, etc feeding practices, road compelling and media in providing 3. Government safety valid information content agencies, media, to foster advocacy groups, widespread, etc sustained and accurate media coverage and thereby improve awareness of economic, social and public health impacts Enhance 4. Study and address 4. Leading role in 4. Think tanks, 4. Requires leadership economic, the impact of building academia, public and funding legal and government partnership with research and 5. Requires better environ- spending and academia, think training agencies, enforcement of mental taxation on health tanks in developing ministries of existing laws policies 5. Develop policies research agenda finance, education 6. Needs leadership and and trade and policy options 5. Government funding agreements, 5. Advisory role and through including provision of Ministries of regulatory data/evidence to Trade, Education, restraints to other government Transport discourage the agencies 6. Think tanks, consumption of 6. Leading role in academia, public tobacco and building research and unhealthy foods partnership with training agencies 6. Study and address academia, think the impacts of tanks, in poor health on developing economic output research agenda and productivity and policy options 74 Policy Goal Challenges Health system Partnership in MENA specific remarks involvement and shared responsibility responsibility Modify risk 7. Deploy proven 7. Advocacy role for 7. Government, food 7. FCTC has been ratified factors measures to the ratification of industry, media, by all MENA countries reduce tobacco FCTC and adoption 8. Ministries of but needs more use, and boost of its imperatives higher education, forceful enforcement resources to (e.g. law on agriculture, etc 8. Needs improvement, implement FCTC tobacco) 9. Municipalities, especially for women 8. Increase the 8. Advocacy role with media, 9. Needs improvement availability and Ministry of government especially for women consumption of Education, agencies, 10. Role of gender needs healthy food agriculture etc professional further attention 9. Promote lifelong 9. Advocacy role associations physical activity 10. Leading role in 10.Think tanks, 10. Better building academia, public understand partnership with research and environmental academia, think training agencies and cultural tanks, in factors that developing change research agenda behavior and policy options Engage 11. Make business a 11. Advocacy role to 11.Ministries of 11. New initiatives businesses partner in relevant commerce, trade, required and promoting government agriculture, 12. A new area for policy community health and agencies, CSOs business development and prevent disease 12. Advocacy role to associations advocacy for most 12. Develop and relevant 12.Municipalities, MENA countries monitor codes government food industry, 13. A potentially very of responsible agencies, CSOs ministry of effective resource for conduct with 13. Advocacy role to education community the food, CSOs, foundations, 13.Faith based mobilization beverage and fraternities, faith organizations, restaurant based CSOs, industries organizations foundations, 13. Empower fraternities, etc community resources such as voluntary and faith based organizations 75 Policy Goal Challenges Health system Partnership in MENA specific remarks involvement and shared responsibility responsibility Mitigate 14. Study and 14. Advocacy role to 14.Think tanks, 14. Needs funding and health risks address how think tanks, academia, public interdisciplinary of poverty poverty academia, public research and research and policy and increases risk research and training agencies development urbaniz- factors training agencies 15.Think tanks, 15. Needs funding and ation 15. Study and 15. Advocacy role to academia, interdisciplinary address the think tanks, municipalities, research and policy links between academia, public research development the built municipalities, and training environment, public research agencies urbanization and training and agencies malnutrition, chronic NCDs, RTIs Reorient 16. Allocate 16. Leading role in 16.Government, 16. Needs a thorough health resource within resource allocation Ministry of understanding of the systems health systems 17. Leading role in planning and NCD related burden based on curriculum finance, of disease and risk burden of development and universities, factors and costing disease training professional studies and 17. Move health 18. Leading role in associations sustainable financing professionals curriculum 17.Ministry of higher of health promotion training and development and education, 17. Revision of practice training universities curriculum may be towards 19. Leading role in professional needed prevention designing financial associations 18. Strengthening health 18. Increase and non-financial 18.Ministries of human resources number and incentives to planning, higher planning skills of influence education 19. Requires reforms in professionals professional agencies, resource allocation who prevent, behavior Universities, and purchasing treat and 20. Leading role in professional modalities and manage chronic adopting policies associations adoption of evidence- NCDs for rational use of 19.Public, statutory based and well 19. Build health cost effective drugs and private targeted systems that for NCDs insurers, interventions for integrate providers, other population-level and screening and entities primary care level prevention 20.Public, statutory programs to prevent within health and private health or delay NCD-related delivery insurance complication, 20. Improve access schemes and disability, and death to medications providers 20. Requires reform in to prevent pricing, complications reimbursement rates, of NCDs access to and use of generic drugs. Adapted from (Daar, Singer, & Persad, 2007) and (Swann, et al., 2010). 76 77 Part 3. Measuring Health Systems Performance and Preparing to Meet the Emerging Challenges The MENA region has made significant progress over the past three decades in terms of expanding access to basic health services. With the exception of Yemen, Iraq and Morocco, most MENA countries indicate reaching above 90 percent coverage in basic health services as self- reported by the national authorities. This section will review how well the health systems in the region are performing in terms of equity, quality and efficiency, or how effective they are in providing value for money. Chapter 4. Understanding the Equity Implications of Out-of-Pocket Health Expenditures I. An Overview of Poverty and Health in the MENA Region Compared to other developing regions of the world, the MENA region has made significant progress in reducing poverty levels, and currently has relatively low levels of poverty. Overall, less than 5 percent of MENA’s population lives on less than US$1.25 per day. Yet, some structural features about MENA make the region particularly vulnerable to various shocks from the poverty perspective. MENA region has a significant number of people living just above but close to the poverty line. While nearly one fifth of the regional population lives on less than US$2 per day, significant numbers live just above the poverty line (The World Bank, 2009). For example, in 2005, about one fifth of Egyptians and Moroccans had per capita daily consumption falling between US$2 and US$2.50, which represents a significant proportion of the population living within this near- poor band. In Yemen and Djibouti, around 15 percent of the populations are found in the near-poor group of households. There are several important implications of these socioeconomic situations in many MENA countries. The poor and the near-poor may feel the need to forego healthcare and subsequently suffer losses in income and employment through untreated illnesses or injuries. The expected rise in the prevalence of noncommunicable diseases and injuries, as discussed in the previous sections, is expected to intensify the vulnerability of these groups to such health shocks by increasing the cost of episode of care as well as by potentially increasing morbidity rates among the working age population and the elderly. Among other concerns, this group of near-poor will be especially vulnerable to health shocks through catastrophic health expenditures which could drive their families below the poverty line. Health programs aimed at extending financial protection to the vulnerable groups will need to include the near-poor as well as the poor. Among all the developing regions of the world, the MENA region has the highest levels of labor force growth, the lowest levels of female participation, and the second youngest labor force after Sub-Saharan Africa. The demographic trends indicate that MENA will continue to face a job creation challenge greater than that of any other region except Sub-Saharan Africa. Women’s labor participation rates has been increasing in recent years, but by next decade it will still remain the lowest among all developing regions. Overall, MENA’s total labor force participation rates will remain the lowest of any developing region (The World Bank, 2007). Furthermore, despite significant improvements in educational attainment, youth unemployment rates in MENA remain among the highest in the world, at around 25 percent (compared to 14.4 percent worldwide), and the gap between unemployment rates among youth 78 and the older cohort is very high (The World Bank, 2007). In Egypt, for example, the unemployment rate for young people aged 15-24 years is 35 percent while that for older age cohorts is below 5 percent (see Figure 29). In addition, MENA youth spend lengthy periods in temporary or intermittent work and spells of joblessness before permanently entering stable employment. Both the high unemployment and informality rates in the MENA region, especially among the youths, will have important implications on their access to healthcare. Most notably, the proposals currently under consideration in a number of MENA countries to expand coverage through a contributory social insurance scheme could be problematic from this perspective (for more discussion, see Chapter 5 Health Financing). Figure 29: Youth and Adult Unemployment Rates in Selected MENA Countries, 2003†† 40.0 35.0 30.0 25.0 15-24 20.0 25-64 15.0 10.0 5.0 0.0 Egypt Jordan Lebanon Morocco Syria Tunisia Source: (European Training Foundation, 2006) II. Coverage and Access to Healthcare in the MENA Region This section will review evidence on the performance of the current healthcare system in conferring social protection in terms of mitigating the effects of catastrophic health payments on household budget and ensuring access to healthcare irrespective of income levels. Most MENA countries have established a network of publicly subsidized services, complemented in some countries by social insurance schemes. Overall, most MENA countries have a system in place that offer near universal coverage for basic health care at no or only a small formal cost the point of use (see Table 11). †† All data for 2003, except for Jordan which refers to 2004. 79 Table 11: Formal health coverage by different programs in selected MENA countries, (latest available year) Est. % of civil population Directly provided government Social health enrolled in health services (Complete or insurance social health Private health Country Partial)/a schemes insurance insuranceb Yemen Yes/Complete No n/a No Libya Yes/Complete No n/a No Lebanon Yes/Partial Yes 31.0 Partial Iran Yes/Complete Yes 69.3 No Egypt Yes/Partial in reformed governorates Yes 45.0 Limited Palestinian Territories Yes/Partial Yes 48.5 No Tunisia Yes/Partial Yes 78.0 Partial Jordan Yes/Partial Yes 44.0 Modest Morocco Yes/Partial Yes 30.0 Partial Kuwait Yes/Complete No n/a Limited Saudi Arabia Yes/Partial No n/a Partial Sources: Yemen, Ministry of Health, 2007; Libya, Ministry of Health, 2008; Lebanon, Ministry of Finance/Ministry of Health Annual Report; Lebanon, percent receiving Ministry of Health-funded treatment, Ammar, 2009; Iran, Household Expenditure Survey, 2006; Egypt, Ministry of Finance/World Bank, Health Policy Note, Public Expenditure Review 2007; Tunisia, Ministry of Health; West Bank-Gaza, Ministry of Health/World Bank Health Policy Note, 2009; World Bank, 2003; World Bank, World Bank, 2005a). Note. a. “Complete� refers to coverage by government health services for all citizens, whereas “Partial� refers to systems that may exclude or require payments by some groups of the population, e.g., Lebanese population covered by social security will not be eligible for free care from the public hospitals. b. “Partial� indicates coverage rate above 10 percent of the population or some sections of the population. Despite the apparent extensive coverage, there is evidence that many individuals in the region face economic barriers in seeking health care. According to available national household survey data, a proportion of citizens in MENA countries report forgoing necessary health care services because of the expected financial costs. In Yemen, approximately 37 percent of respondents have reported not seeking health care due to financial barriers. In other countries, response to a similar question in the household surveys revealed that in Lebanon around 20 percent reported foregoing care, 18 percent in Libya and 12 percent in Egypt, as shown in Figure 30. Figure 30: Forgone health care use due to financial costs in MENA 80 Egypt Lebanon Libya Yemen 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% Percent of population who forgo care due to financial costs (%) Sources: Yemen, Household Budget Survey 2005/6; Lebanon, Multi-Country Survey Study, World Health Organization, 2001; Libya, Household Expenditure and Consumption Survey, 2003/4; Egypt, Multi-Country Survey Study, World Health Organization, 2001. A number of surveys also reveal the extent to which financial barriers exist in the region. According to the 2008 Demographic and Health Survey for Egypt, some 44 percent of women reported financial constraints as a significant barrier to accessing healthcare (see Table 4 in Chapter 2, above). In Morocco, about 34 percent of users of hospital services reported that they were treated badly by the providers due to “lack of wealth� (WHO Multi-Country Health System Responsiveness Survey, 2002). While these latter two surveys asked questions indirectly and therefore the figures need to be interpreted with caution, they nevertheless point to a significant number of people facing financial barriers to access in many MENA countries. A more systematic and regular assessment of barriers to access to health care would be necessary to obtain III. Trends in Out-of-Pocket Spending by Households The relative size of out-of-pocket (OOP) health spending as a percentage of total health expenditures is often used as one measure of assessing the extent to which the country’s risk pooling mechanism is functioning. Low income countries tend to have relatively high share of OOP (47 percent global average), as the institutional capacity for risk pooling remains limited and the total cost of healthcare remains relatively low. As income levels grow, and countries increase the share of total health spending which is funded through some form of a risk pooling mechanism, either through government revenues, social insurance systems, or supplemental private insurance schemes. In middle income countries, OOP accounted for around 32 percent of total health spending, and high income countries around 20 percent. In MENA, health care expenses often comprise the single largest component of household expenditure after food. In seven MENA countries surveyed as depicted in Table 4 below, households reported spending between 3 percent and 7 percent of their total consumption expenditure on health care-related services. The OOP health expenditures also accounted for a relatively higher share of total health expenditures in comparison with the global averages at similar income levels (see summary Table 12). 81 Table 12: Out of pocket (OOP) Spending as Share of Total Health Expenditures – MENA and Global Averages, 1995-2008 Country 1995 2008 % change GCC Mean 25.76 22.72 -12% Global High Income Mean 22.08 20.84 -6% MENA Middle Income Mean 43.62 40.03 -8% Global Middle Income Mean 35.38 32.23 -9% Yemen 65.51 58.01 -11% Global Low Income Mean 50.03 45.77 -9% See Section XX on Health Financing. Among the high income GCC countries, the share of OOP at 23 percent is close to global average, confirming that these countries provide a relatively good coverage and financial protection for their population. But the MENA middle income and low income countries show a significantly higher rate at 40 percent and 58 percent, respectively, compared with the global average of 32 percent among Middle Income Countries and 47 percent among Low Income Countries (see summary in Table 12). As will be discussed below in Chapter 6, below, the overall trend has been a decrease in the share of OOP over the past 15 years. But in a number of countries (Egypt, Morocco, Iran, Tunisia and Jordan) the trend has been towards a further increase in OOP as a share of total health expenditure. These trends are of concern, as they suggest that the risk pooling and financial protection mechanisms in these countries may not be keeping pace with the changing demands for healthcare, and more households are being exposed to increasing financial burden of healthcare. That this is occurring at a time when these countries still have a relatively young population profile adds weight to that concern: as the population ages and the prevalence of noncommunicable diseases rises in these countries, the likelihood of these households facing catastrophic health payments will increase. The OOP spending pattern has been further disaggregated by urban/rural spatial differentiation, and by income quintile groups in selected countries. These trends are summarized in Table 13 and Table 16, below. Data by geographic status show that out-of-pocket payments reveal further differences across countries. In Yemen, Libya and Tunisia, households in urban and rural areas appear to pay similar proportions of their expenditure on health care on average. In Iran, Lebanon and Egypt, wide gaps exist; healthcare accounts for a greater proportion of household spending in urban areas than in rural areas. Table 13 Average out-of-pocket spending on health care in selected MENA countries, urban /rural differences GDP per capita, OOP as % Total Average OOP as % HH Income (%) 2006 (current Health Country International $) Expenditure Total Urban Rural Libya 9,225 20 3.0 3.0 2.9 Lebanon 6,060 75 6.6 n/a n/a Iran 3,152 44 5.1 4.9 6.1 Tunisia 3,072 56 4.6 4.4 4.8 82 GDP per capita, OOP as % Total Average OOP as % HH Income (%) 2006 (current Health Country International $) Expenditure Total Urban Rural Egypt 1,489 62 8.9 9.2 8.5 Palestinian Territories 1,187 40 3.1 3.3 3.2 Yemen 882 58 2.7 2.8 2.5 Sources: GDP data: Current international dollar; World Economic Outlook, April 2009 Database, International Monetary Fund; West Bank-Gaza based on IMF West Bank-Gaza Staff Report February 25, 2009. OOP expenditure: Authors’ calculations based on household survey data: Egypt figures based on Household Income, Expenditure and Consumption Survey 2004/5 for total expenditure and Health Insurance Survey 2006 for OOP; urban and rural figures approximated; Lebanon Multipurpose Survey on Households 2004/5; Iran Household Income and Expenditure Survey 2006; Palestinian Consumption and Expenditure Survey, Palestinian Central Bureau of Statistics, 2006; OOP as % Total Health Expenditure based on West Bank-Gaza Health Policy Note, World Bank, 2009. Notes: International Dollar = purchasing power parity exchange rate. OOP = out-of-pocket expenditures on health care. HH = household. Table 14: Distribution of out-of-pocket health care spending (OOP) across income quintile Country Proportion of total household expenditure spent on Concentration health care across income quintile (%) Index‡‡ Poorest 2nd Middle 2nd Richest Total Poorest Richest Yemen (2005/6) 1.7 1.8 2.2 2.5 3.7 2.7 0.1970 Libya (2002/3) 2.1 2.6 3.0 3.3 3.7 3.0 0.1039 Lebanon (2004/5) 4.8 6.3 6.5 7.5 8.2 6.6 0.0960 Iran (2006) 4.3 4.2 4.1 4.2 5.9 5.1 0.0569 Egypt (2006/7) 5.2 3.1 4.4 3.7 1.0 3.4 -0.1888 Palestinian Terr. (2006) 3.0 2.9 3.1 2.9 3.5 3.1 0.0162 Tunisia (2005) 4.0 4.3 4.4 4.7 5.1 4.5 0.0346 Sources: See Annex 8 for details. Yemen Household Budget Survey 2005/6; Egypt calculations based on data from 2007 health survey in four governorates (Alexandria, Menoufia, Suez and Sohag) used to measure policy effectiveness at exempting poorer households from user fees; Lebanon Multipurpose Survey of Households 2004/5; Libya Economic and Social Survey, 2006; Iran, Household Income and Expenditure Survey, 2006; Palestinian data based on Palestinian Consumption and Expenditure Survey, Palestinian Central Bureau of Statistics, 2006; Tunisia Health Survey 2005. These household survey data show that among the countries surveyed in the MENA Region, the share of OOP spent by households tends to be higher in absolute and relative terms among higher income groups, with the richest quintiles spending nearly double that of the poorest on health care. Among the countries analyzed, Egypt is the exception, with lower income groups paying a higher share of their household budget on healthcare. The interpretation of these trends requires great caution, as there are multiple factors contributing to these trends including the availability of the supply of services, the level of needs and demand for services; and the level of subsidies being directed to different groups of beneficiaries. First, the OOP trends must be reviewed in conjunction with utilization data to understand whether they lower income groups are making greater or lesser use of services in terms of the volume of services as well as the intensity and quality of services received. Secondly, ‡‡The Concentration Index is a measure of how equally a health variable is distributed across a population ranked by income level. 83 the review of OOP trends should be closely complemented with the analysis of subsidies being utilized by different categories of the population, such as through benefits incidence analysis. For example, in Egypt, the same household survey also showed that the lower income groups made less use of healthcare in terms of the volume of services. The same survey showed the ineffectiveness of the policy exempting the poor from copayments, suggesting that the efforts to target the subsidies to the poor may not be working well. The Demographic and Health Survey 2008 also showed that women in lower income groups face financial and other barriers to healthcare (unmet needs). These pieces of evidence taken together suggest that in Egypt, the poor are paying a higher share of their own household budget towards healthcare, but even at with this higher share they are still using services below the level they need. Furthermore, there is an indication that government subsidies are not being effectively directed to mitigate the financial burden of healthcare for the poor, but a more detailed benefits incidence analysis will be required to show the magnitude of this effect. In Yemen and Libya, citizens have reported having had to travel abroad for health care services due to the lack of availability or satisfaction with local services. Overseas treatment accounts for a large share of OOP in these countries, and they are more likely to be used by higher income quintile groups. These trends suggest that higher income groups are consuming more expensive and possibly higher quality services than the poor, which account for the higher share of OOP spending among this group. In Tunisia, there is evidence that on average the insured population groups pay significantly higher OOP compared with the uninsured group. These trends suggest that the insured might have access to better (and possibly more expensive) supply of healthcare services, and are also making greater use of healthcare services due to partial subsidization of benefits. In doing so, they may also face significant copayments and other user charges. As will be discussed in Chapter 5, below, there is evidence that the public hospital services may be under-financed in some facilities in Tunisia, and some of the costs of care are possibly being shifted onto the patients. In Iran, there is a similar trend emerging, in which the insured population group in the rural areas are beginning to face catastrophic payments approaching the level of the uninsured population (see Box 5, below). The exact cause of this effect will require a more in-depth analysis of the use of services in the local context. They also point to the critical importance of closely monitoring the effectiveness of health insurance programs as they are rolled out over time. 84 Box 5: Evolution of Health Insurance Coverage and Catastrophic Payments in Iran The extent to which health insurance schemes protect households against catastrophic health care payments depends on the scope of the coverage and eligibility criteria, amongst other factors. Examining the case of Iran during 1996-2006, uninsured households have tended to face approximately twice the exposure to catastrophic health care payments. Between 2001 and 2006, there was a significant improvement in health insurance coverage due to the introduction of the Rural Health Insurance scheme in 2005 (see Table 15) to the point where the coverage rate now exceeds that of the urban population. An analysis of catastrophic payments show that in 2006, approximately 7 percent of insured households reported catastrophic payments as compared to 14 percent of uninsured households as shown in Table 15: Spatial distribution of health insurance coverage over time in Iran, 1996-2006 Proportion of households enrolled in health insurance (%) Rural Urban 1996 28.46 61.12 2001 33.29 60.91 2006 76.24 61.18 Source: Iran, Household Expenditure Survey, 1996-2006. Figure 31. Over the past two decades, the expansion of health coverage to rural areas was associated with improved access to primary health care services focused on maternal and child healh services. But with the increase in noncommunicable diseases, the coverage has been extended to a more comprehensive package under the Rural Health Insurance Program. Since the introduction of that program, the insured rural households reported a substantially higher rate of catastrophic payments. This may reflect, on one hand, the improved availability of health care services (supply side) and potentially increased exposure to copayments and other user charges for households who are making more use of services that they might have otherwise forgone. Table 15: Spatial distribution of health insurance coverage over time in Iran, 1996-2006 Proportion of households enrolled in health insurance (%) Rural Urban 1996 28.46 61.12 2001 33.29 60.91 2006 76.24 61.18 Source: Iran, Household Expenditure Survey, 1996-2006. Figure 31: Spatial distribution of catastrophic expenditures by insurance status in Iran over 85 time, 1996-2006 Catastrophic Expenditures by Insurance Status in Iran 14 health expenditures (% of Incidence of catastrophic 12 UI - Rural 10 UI- Urban households) 8 UI - Country 6 INS - Rural 4 INS -Urban 2 INS - Country 0 1996 2001 2006 Year Source: Authors’ calculations using data from national surveys. Note: Catastrophic spending in Iran is defined as at least 25 percent of total household expenditure. UI = Uninsured; INS = Insured. IV. Assessing the financial burden of healthcare spending To assess the burden of out-of-pocket payments and catastrophic expenditures, the extent to which health care payments impinge on living standards has been evaluated in selected MENA countries. OOP health care payments may pose a source of strain on household resources due to the uncertainty of their timing, duration and magnitude. Figure 32 shows the proportion of households who faced catastrophic health expenditures (defined as at least 10% of total household expenditures) in seven MENA countries. Figure 32: Incidence of catastrophic health expenditures in MENA countries 14.0% incurring catastrophic health care 12.0% Proportion of all households 10.0% expenditures (%) 8.0% 6.0% 4.0% 2.0% 0.0% Yemen Libya Lebanon West Bank Egypt Tunisia (2005/6) (2003/4) (2004/5) and Gaza (2007) (2005) (2005) Source: Calculated using data from national household surveys. 86 Note: Catastrophic spending is defined as having incurred at least 10% of total household expenditures. Table 16 shows that health care payments in selected MENA countries impact poverty levels differently across countries. While the effect appears to be negligible in Libya – the wealthiest of these countries, OOP health expenditure increases the number of households that fall below the poverty line in the others: Palestinian Territories, Lebanon, Iran, Egypt, and Tunisia. Table 16: Effect of out-of-pocket health care payments (OOP) on poverty rates in MENA countries Pre-payment Post-payment Absolute poverty poverty difference Relative difference headcount (% of headcount (% of (percent (percentage Country households) households) difference) difference) Yemen (2005/6) 20.3 21.9 1.6 7.9 Libya (2003/4) 1.7 1.8 0.1 5.6 Lebanon (2004/5) 27.5 31.6 4.1 14.9 Palestinian Territories 13.7 25.1 11.4 82.9 (2005) Iran (2006) 13.6 15.4 1.8 13.2 Egypt (2007) 31.8 36.1 4.3 13.5 Tunisia (2005) 3.7 4.4 0.7 17.8 Source: Authors’ calculations using data from national surveys (see Volume 2). Notes: Data for Egypt shown for baseline levels before introduction of user-fee exemption scheme. Consistent with the patterns of poverty within countries, the effect of health care payments varies geographically (Table 17). Using the cases of Yemen and Libya, overall poverty rates are generally two to three times as high in rural areas than in urban areas, as tends to be the case throughout MENA countries. At the same time, Yemeni urban households face the effect of health care payments more intensely than their rural counterparts; the relative differences in headcount and the gap are higher amongst urban than rural households. In Libya, it is rural households that face a greater intensity of poverty after health care payments are taken into account. Therefore, spatial differences in the effect of health care payments should be taken into account when designing appropriate health financing schemes within a given country. Table 17: Spatial distribution of OOP-related impoverishment in MENA countries Poverty Headcount (%) Poverty Gap (%) Country Pre-payment Post-payment Relative Pre-payment Post- Relative poverty poverty difference payment difference Yemen (2005/6) 20.30 21.90 7.88 5.85 6.32 8.03 Urban 14.90 16.40 10.07 3.99 4.37 9.52 Rural 31.10 33.25 6.91 9.48 10.22 7.81 Libya (2003/4) 1.70 1.80 5.56 73.70 73.70 0.00 Urban 1.40 1.40 0.00 57.30 59.60 4.01 87 Rural 3.70 3.70 0.00 161.30 175 7.83 Source: Authors’ calculations using data from national surveys (see Annex 8). V. Next Steps A. Meeting the Challenges Although poverty rates in MENA countries are relatively low, the existence of a large population of near-poor makes them particularly vulnerable to impoverishing effects of catastrophic health expenditures. Among the 7 countries surveyed in this report, OOP health expenditures tend to increase the poverty headcount by 5 – 14 percent, with the exception of Palestinian Territories where the headcount increased by as much as 80 percent. These vulnerabilities emphasize the importance of extending financial protection against catastrophic health payments not only to the poor, but to the near-poor who are especially vulnerable to the impoverishing effects of ill-health. Few countries in the MENA region have well-developed, targeted safety nets. Most programs rely heavily on highly expensive consumer subsidies, which often suffer from both poor coverage and a high degree of leakage to the non-poor. Egypt’s food and energy subsidies, for example, absorb some 30% of public expenditure (and about 10% of GDP), but are not available to a large segment of the poor. In Morocco, the poor are receiving only 10% of what the government spends on universal price subsidies, while 90% goes to subsidizing goods consumed by the non- poor (The World Bank, 2009). While a number of MENA countries are taking steps to improve the efficiency, targeting and coverage of social safety net mechanisms, progress has been slow. This general weakness in the social safety net programs in the region has significant implications on the design and effectiveness of the health system in ensuring adequate protection from catastrophic financial outlays due to illness or injuries. First, the existence of the sizeable subsidies limits the fiscal space for allocating needed resources to expand health benefits or increase subsidies to the vulnerable population. Secondly, the lack of effective social targeting mechanisms limits the scope for targeting the vulnerable population who should be eligible for subsidized health care. Thirdly, social safety net programs will need to be enhanced to include community outreach component that addresses socio-cultural barriers to access. The shortcoming in this last area was especially evident, for example, in the introduction of the policy to exempt the poor from paying premiums or copayments in Egypt. During 2006 and 2007, four Egyptian governorates participated in a user fee exemption system as part of the pilot social health insurance program. In the initial phase of implementation, the scheme was unable to demonstrate that the exemption scheme reduced the financial burden on the targeted population. The lack of impact has been attributed in part to the absence of any social outreach programs to inform the potential beneficiaries about the exemption scheme and a complementary program to incentivize health personnel to extend services to the exempted population group. This example demonstrates that introduction of social targeting and exemption schemes must be matched by comprehensive systems to ensure that beneficiaries are empowered to take advantage of the program and the providers are ready to provide services to this group. Finally, social insurance systems in the MENA region remains limited in extent of coverage and scope of benefits. The existence of a large number of unemployed and informal sector workers, as noted above, presents a major challenge in extending health insurance coverage through a traditional social health insurance scheme. Because participation in social insurance schemes are 88 usually predicated on beneficiaries making prepayment contributions in the form of a premium or payroll deduction, those who are unable to pay (the poor) or who are not part of the formal economy are less likely to participate. This could lead to exclusions of the most vulnerable categories of the population, notably the poor and informal sector workers and their families. Therefore, any expansion of social health insurance programs will need to be accompanied by concurrent programs of social outreach and social protection to ensure the full participation and inclusion of these groups in the program. D. Focus on results –Steps to Reduce Financial Risks Due to Illness and Injuries A number of low and middle income countries in the region are beginning to address the need to reform the existing energy and food subsidies in order to free up additional fiscal space better targeted social programs. As subsidy reforms are implemented in phases and fiscal space becomes available, it would be important to ensure that the priority health policies and programs are explicitly included as the recipients of these additional resources. This will require strong justifications in terms of the cost-effectiveness of the interventions and the long-term benefits in terms of economic impact and social welfare gains that will accrue as a result of investing in these health policies and programs. Among the priority programs that should be in this list would include funds to subsidize access to basic health coverage for the poor and the near-poor, as well as public health programs that will promote healthy lifestyles and prevent health risks. This will require the introduction of effective social targeting system, which is not yet in place in MENA countries. A number of countries are beginning to initiate programs to introduce effective targeting mechanisms, but they are often carried out separately from health sector reform activities: a better coordination and integration of efforts will be needed to avoid duplication of efforts. At the same time, social targeting on its own - while necessary - will be insufficient for achieving behavioral changes on the part of both the beneficiaries and healthcare providers. The actual availability of services in the under-served areas and the appropriate use of healthcare services by under-served population groups will require an active program of incentives to the providers and empowerment for the citizens. Designing and effective program to achieve this will require a close cooperation and partnerships among the beneficiary groups, the professionals who provide the services, and the state which will be financing the subsidies. Poverty reduction and social protection strategies should explicitly take into account the household risks associated with catastrophic health expenditures in order to mitigate against their impoverishing effects. Financial protection against catastrophic health spending will need to be extended as also to those groups with a higher-than-average need for health care, such as infants, mothers, the elderly and the disabled, and those with chronic conditions such as those associated with non-communicable diseases, HIV/AIDS, or injury-related disabilities. While the appropriate policy response to improve equity in health care is best designed by a careful assessment of local needs, the following key policy features will require attention: (a) Ensure close linkage between the design of the health coverage plan and the ongoing social targeting initiatives in the country, including collection of accurate information on beneficiary welfare through national registry and effective information systems for social targeting. (b) Inclusion in the social safetynet of the near-poor group who are highly vulnerable to the impoverishing effects of catastrophic health expenditures. 89 (c) Introduction of effective incentive systems for health care personnel to provide quality services to the under-served population. (d) Development of effective community outreach programs to encourage and empower citizens to utilize health services effectively in under-served areas, and to reduce socio- cultural barriers to access. (e) Well-designed risk-pooling schemes, including the development of supplementary private insurance plans to reduce the financial risks of catastrophic health expenditures for all income levels, including the non-poor who are also vulnerable to catastrophic health payments. The importance of extending financial protection to families will increase as the cost of health care is expected to increase due to ageing population and the rise in NCDs. 90 Chapter 5. Aspiring for better health system performance for better health in MENA A. Why emphasis on health system performance? All health systems aspire to achieve three fundamental goals: (i) improve health across all segments of the society: (ii) be responsive to people’s expectations and preferences; and (iii) ensure that financial consequences of ill-health are borne out by the society at large without causing undue welfare loss to, and impoverishment of the sick, his/her family and community. Accordingly a health system will be performing well if it could score high on all these three goals, a tall order for any health system, regardless of how well endowed or under (fiscal) strain it may be. Health systems strive to achieve these goals while trying to remain effective and efficient to safeguard their long term viability and sustainability. Assessing performance of health systems has become prominent, especially in North America and Europe, with the increased emphasis on/preoccupation with improving value in health care, or in lay terms, achieving better health outcomes and patient satisfaction while containing costs. Four trends have contributed to the increased emphasis: (i) ever escalating health care costs in almost all countries, albeit at different rates, but often at a rate higher than the GDP growth; (ii) perennial concerns over failures in the health care market, either as a result of “moral hazard�, or propensity to use health services by the population when there are no financial or other costs involved, and/or because of the “supplier induced demand� that is health providers inducing or creating demand for services that are not needed or medically justifiable; (iii) increased concerns over patient safety and informed decisions about their treatment choices; (iv) availability of new applications of Information Communication Technology (ICT) in health system information that has significantly improved the system capacity to gather and manage large amount of information efficiently, taking advantage of the technological advances that has improved the user interface and ease of adaptation to complex business processes, and substantially reduced costs in information technology. There is a growing international recognition that health systems needs to be subject to the same degree of performance assessments as in any other sector, and the availability of information technology to process the enormous amount of information in real time has significantly increased the system’s capacity to respond to this growing demand from the Governments, employers, and the general public for greater accountability in the sector. This does not only mean that all the production factors, that is capital, labor, infrastructure, know-how and technologies should be there in sufficient quantity and be deployed geographically in an equitable and efficient manner, but it also means that the all these factors should produce the right volume and mix of services that are safe, appropriate and technically of high quality and that they are delivered in a comprehensive, continuous and respectful manner to those who need them. It is therefore crucial that health systems continuously assess their achievements and compare them with those of comparable others to assess their performance, draw lessons from weaknesses and shortcomings and take corrective actions. Achieving and demonstrating measurable improvement in the performance of their health systems will require partnership 91 between the government and the broader non-governmental sector, including professional associations, business leaders, civil society and consumer advocacy groups. VI. What is meant by performance? Health system performance is usually assessed at the sectoral level, typically by measuring a set of health outcome metrics (e.g., maternal mortality, life expectancy, etc) against expenditures (e.g., total health expenditures – see Figure 33). Figure 33: Maternal mortality ratio and per capita health expenditures – global trends and MENA While such assessments are important to have a broad view of system performance, they are less useful for identifying specific actions since they do not disaggregate the impact of the multiple factors that may be contributing to the overall mortality rates, including factors outside the healthcare system, such as environmental and behavioral factors, and those which are more directly linked to healthcare services, such as access to health services, quality of care, responsiveness. One study on 19 industrialized nations estimated that mortality that can be prevented through interventions of the healthcare system accounted for 23 percent of male and 32 percent of female mortality before the age of 75 (Nolte and McKee, 2008). Another study found that one of the reasons why the US spends 50 percent more on healthcare than in France is attributable to higher rates of obesity and smoking among the American populations (Sturm, 2002). These studies suggest that much more attention needs to be paid to health promotion and other life-style and behavioral factors in order to achieve better health outcomes for the nation. Nevertheless, spending on healthcare is significant and growing in all of the industrialized countries, and its 92 performance will be a critical element in contributing to good health outcomes and its financial sustainability and affordability in the long term is of paramount concern. For the low and middle income countries which have much less institutional capacity to collect and manage information, the ability to assess performance in the health sector has been that much more constrained and much of the analysis has remained at the broad, macro-level assessments and at the facility-level, the information has been primarily limited to supply of inputs rather than on outputs or outcomes. It will be argued that this level of analysis will no longer be adequate in ensuring effective management, and that even using very selective and limited number of indicators it will become necessary to collect information on and assess the performance of healthcare on quality at a more disaggregated level. For example, among the low income countries, the Kyrgyz Republic is well known for having made a remarkable progress in improving access to health services for its citizens despite limited resources (US$36 per capita total health expenditure in 2006), thereby making basic health care more affordable and efficient while expanding choice. Furthermore, Kyrgyz system allows the performance measures at the facility-level, thus allowing the information on performance to feedback to the management level for decision making. A recent assessment of the Kyrgyz health system found that the indicators of equity, access and efficiency had improved, but those related to quality of care was lagging. Consequently, improved access to affordable care was not translating into improvements in health outcomes due to quality issues.§§ The growing trend in the health sector performance assessment has been to focus on care settings (e.g., hospitals, primary care, etc) or domains (e.g., pharmaceuticals) and disease pathways (e.g., diabetes, cardiovascular diseases) for a in-depth assessment at these disaggregated levels to determine and act on issues related to appropriateness and quality of care, including efficiency (See Table 18). §§ Manas Taalimi Health Reform Program: Joint Mid-Term Review, World Bank Aide Memoire, May 2008. 93 Table 18: Different Approaches to Performance Assessment in Healthcare Levels of Advantages Disadvantages performance assessment Health system  Holistic (macro-level perspective)  Difficult to disentangle healthcare  Goal oriented – can be linked to outcomes from health outcomes, i.e. equity and other national policy attribution to factors outside of objectives healthcare setting, including social  Can be the basis for overall determinants of health, inter-sectoral accountability of the Government factors  Comparability through  Accountability can be diffuse benchmarking at broad population  Value for money not always clear – levels difficult to identify specific bottlenecks and magnitude of problem associated with that bottleneck  Less actionable and quantifiable investment requirements Settings  Shared accountability  Focus on the care provided within the (facilities or  Emphasis on governance and facility, not necessarily coordinated with domains) management at the level where the other levels of care. decisions can be made and  Alignment with health sector objectives implemented immediately not always evident, especially if the  Emphasis on different aspects of facility operates on its own without performance can be made more regulation or reference to peers (e.g., specific and measurable, including through accreditation) efficiency, safety, clinical outcomes,  Consideration of alternative options (and patient responsiveness allocative efficiency) can be overlooked,  Comparability across similar e.g., prevention, unless multiple options healthcare providers are explicitly considered – e.g., in an  Benchmarking integrated healthcare setting  More actionable  Less emphasis on integration and coordination of care, unless evaluation takes place in an integrated care setting  Risk adjustments will be needed to account for difference in socioeconomic and morbidity mix  Less emphasis on sustainability and equity unless explicitly included in evaluation  Value for money not always clear 94 Levels of Advantages Disadvantages performance assessment Disease  Patient-centered: better alignment  Narrower focus on patient rather than on pathways of incentives for continuity of care, the population as a whole (episodes of patient responsiveness  Appropriateness of care at the population illness or care)  Streamlining of care process: allows level may not be evident, and adjustment better integration and coordination for different population groups will across multiple settings require other approaches  Better delineation of costs across  Accounting for co-morbidity and severity the episode and better alignment of will be a challenge financial incentives  Comparability across settings  Allows monitoring by episode of  Less emphasis on sustainability and illness and episodes of care allocative efficiency (longitudinal)  Value for money clear at the episodic  Prevention is valued level only  Accountability clearer and shared across different care givers  Allows balanced evaluation of quality, costs and outcomes at the patient level  Provides valuable insights into how healthcare delivery system performs from patient perspective Measuring health system performance in all its dimensions is complicated because of the inherent complexity of health systems. Healthcare involves complex procedures requiring coordination among diverse groups of specialized personnel (e.g., general practitioners, specialists, nurses, midwives, technicians, pharmacists, administrators), goods (pharmaceuticals, medical devices and supplies), and infrastructure (e.g., hospitals, clinics, laboratories). These interventions are also subject to constantly changing technologies. The very complexity of the services, combined with the rapid pace of technological innovation, has made healthcare notoriously difficult to monitor and evaluate. On the other hand, no health system can afford not to assess its performance because of the divergent needs of its stakeholders: Patients would like to be assured of the availability of appropriate services when they need them; physicians and providers would like to know if that are providing high quality care and respond to the needs of their constituency: payers would like to make sure that their money is well spent in line with their expectations: and governments/regulators/policy makers that the healthcare market functions efficiently and that they generate value and create welfare through improved health and productivity (Smith, Mossialos, Papanicolas, & Leatherman, 2009). Among the high income countries, the concern over improving value in healthcare is real and pressing. In its groundbreaking report “To Err is Human�, the Institute of Medicine (Institute of Medicine, 2001) estimated that up to 100,000 people may be dying as a result of medical errors, much more so than traffic accidents. The study found a substantial gap (a “chasm�) between the evidence-based best practice and actual practice: what was particularly surprising was the magnitude of the gap, which was extensive and covered all levels of practices and specialties. Similar evidence of quality gaps and measurement problems are also being found in other higher income countries (OECD 2004). In Scandinavia, about 12 percent of hospitalized patients 95 experience adverse effects 70 percent of which is preventable, over half of which lead to disability and increased length of stay. In England, 40 percent or 1.9 million hospital emergency admissions were avoidable if better primary care had been provided (WHO Regional Office for Europe: Briefing on Patient Safety April 2010). In the European Union, healthcare associated infections (HCAI) affect an estimated one in twenty hospital patients on average every year (estimated at 4.1 million patients). RAND estimates that strategies aiming to reduce adverse events in the EU would lead to the prevention of more than 750,000 harm-inflicting medical errors per year, leading in turn to the reduction of more than 3.2 million days of hospitalization, 260,000 fewer incidents of permanent disability, and 95,000 fewer deaths per year (Vilamoska, 2009). Among the OECD countries, there is an emerging consensus to define and measure quality of healthcare along the following dimensions (Agency for Healthcare Research and Quality 2003; OECD 2004):  safety (for patients and providers);  effectiveness (clinical efficacy);  timeliness;  efficiency; and  patient-centeredness (responsiveness to patient needs, preferences) The proposed OECD and AHRQ framework presents a very comprehensive, highly complex and challenging set of dimensions to measure and evaluate. While this has stimulated new research in the OECD countries, the measurement instruments being developed in high income countries are costly and data-intensive, and may not always be affordable or feasible in a lower income setting. For health policy makers in the developing countries the situation presents a particularly difficult challenge: the proliferation of new approaches for measuring performance on quality and efficiency is making it difficult for policy makers to know where to start or how to select the most appropriate set of indicators, especially in a resource constrained context. At a minimum, it would be recommended that the countries start by reviewing the current status of their existing health system and identify how well they are doing in measuring performance against the five major dimensions identified above, and at the facility and patient/episode level. In the next section, we will review available data on how some of the MENA countries are performing from this perspective. E. Salient performance issues in MENA The MENA region has made a remarkable progress in expanding access to basic health services for its citizens over the past three decades and in improving health outcomes (Table 19). As discussed in the previous chapter, the MENA region now faces a major health transition with the increase in non-communicable diseases as the most prevalent burden of disease. This change in population health profile will bring about profound changes to the healthcare needs and demands, and will bring about changes in the volume, scope, nature, intensity and mix of health services that are required to meet them. This will mean that making sure that those services are of acceptable technical quality and responsive to populations’ expectations. 96 Table 19: Access to basic health services in selected MENA countries and performance of health outcomes (under 5 mortality rates and maternal mortality ratios) relative to health spending levels Under-5 Maternal mortality rate mortality ratio Births Population Population above (+) or above (+) or Immunization, Immunization, attended by with access with access below (-) below (-) DPT in 2007 measles in skilled to local to local predicted for predicted (% of children 2007 (% of health staff health health the level of value for the ages 12-23 children ages (% of total services services health level of health months) 12-23 months) births) Year (urban) (rural) Year spending spending Algeria 95 92 95.2 2006 .. .. +/- + Djibouti 88 74 92.9 2006 100 n/a 2002 + + Egypt 98 97 74.2 2005 100 100 2008 - - Iran 99 97 97.3 2005 100 95 2008 + + Iraq .. .. 88 2006 98 87 2008 n/a n/a Jordan 98 95 99 2007 100 96 2001 +/- +/- Lebanon 74 53 98 2004 99 97 2000 + + Libya 98 98 100 2006 100 100 2008 - + Morocco 95 95 61 2004 66 77 2008 + + Palestinian Terr. .. .. 98.9 2006 100 100 2008 n/a n/a Syria 99 98 93 2006 100 90 2008 - - Tunisia 98 98 95 2006 100 100 2008 - +/- Yemen 87 74 35.7 2006 80 25 2008 + + GCC Bahrain 97 99 99 2005 100 100 2003 - + Kuwait 99 99 98 2006 100 100 2003 +/- - Oman 99 97 98.1 2006 100 95 2008 - + Qatar 94 92 100 2006 100 100 2002 + + Saudi Arabia 96 96 96 2004 100 95 1996 + - United Arab Emirates 92 92 100 2006 100 100 2008 - + Sources: The World Bank, World Development Indicators, 2009; and WHO EMRO Health System Observatory Data Base. A major challenge in assessing the quality and efficiency of health care in the MENA region is the lack of standardization in and fragmentation of the collection and reporting on key health indicators needed to measure overall performance. A review of the health systems performance in the MENA Region shows that the data on healthcare are generally focused on indicators related to inputs and supply of services, but the quality and efficiency dimensions of healthcare are rarely monitored routinely. While a number of initiatives are being taken to address these issues in the Region, the state of health care monitoring, research and evaluation in the areas of quality and efficiency remains very limited. For example, a review of a key supply side indicator – number of hospital beds per population – shows that this figure generally low in the MENA region relative to the rest of the world . Data on average bed occupancy shows variation across the region from 37 percent to 80 percent. Are these low rates indicative of an efficient use of hospital services, or do they point to inadequate investments in hospitals? A bed occupancy rate of less than 80 percent is generally considered inefficient, and is suggestive of underlying inefficiencies in the use of 97 resources. But care should be taken in interpreting these average figures; much more detailed information on the different dimensions of hospital performance will be needed to arrive at a meaningful conclusion about the quality and efficiency of care in these countries. In the following section, we will review the evidence from the MENA region which provide some indications of the status of different dimensions of quality and efficiency in the healthcare system in the region. It is apparent that throughout the MENA region, there is a very serious paucity of data on service utilization, including quality and cost of care, and only partial picture emerges on the performance of healthcare in the region. A. Management of non-communicable diseases – Diabetes Case Management in Egypt To explore whether the current health systems are indeed capable of coping with the increasing burden of noncommunicable diseases, it is necessary to explore the data more deeply to determine how the MENA countries are dealing with the performance of healthcare with respect to this category of diseases. NCDs differ from communicable diseases in some important ways: NCDs generally require long-term follow up, often at primary care level if outcomes are to be acceptable and costs minimized, and they also often require long term use of pharmaceuticals. Treatment of NCDs, especially in late stages of the disease, can be very costly. It is important therefore, that there is an effective primary care network in place, tests and medications are affordable, and that best clinical practice is followed. Diabetes is a good example of a noncommunicable disease that is often associated with unnecessary morbidity and cost. As part of the assessment of NCDs in the MENA Region, the World Bank and World Diabetes Foundation, in collaboration with the Egyptian Ministry of Health, convened a two-day work shop in Cairo entitled “Diabetes in Egypt: Towards a National Diabetes Program� on June 25-26, 2008. The following section summarizes the main findings and discussions from this national workshop. Prevalence of Diabetes and Related Risk Factors. According to a survey conducted in 2006 by the Epidemiology and Disease Surveillance Unit of the Ministry of Health, the national prevalence of diabetes in Egypt is estimated to be 7.2% among persons aged 15-65 years of age, but more than 16% among 25-65 year olds – an extremely high rate by any standards.*** The same survey also reported on risk factors for chronic diseases (both diabetes and cardiovascular disease). The results indicate that there are numerous risk factors of high prevalence in the surveyed population. Overweight and obesity, in particular among women, was very widespread, with more than 72 percent reporting a BMI>25 (among men the corresponding percentage is 60). Almost 80% of the population consume less than the recommended servings of fruits and vegetables, more than half (51%) have a sedentary life style, and a third have elevated blood pressure, and 18% smoke (35 percent of men smoke). Overall, less than 3% of the population have none of five key risk factors (overweight/obesity, smoking, sedentary lifestyle, hypertension, and low intake of fruits and vegetables). This situation indicates that the prevalence of diabetes, along with cardiovascular diseases, will likely increase rapidly in the coming years. Diagnosis, Management, and Complications of Diabetes. Data from the 2006 diabetes survey suggest that diabetes is significantly under-diagnosed, with only 53 percent of diabetics actually diagnosed as such (Figure 34). However, this average hides very large variations both across sex *** The validity of this study has been questioned by the national diabetes specialists, although the survey methodology was technically sound and the survey was carried out in collaboration with WHO according to international standards. 98 and age-groups. Overall, men have much higher rates of under-diagnosis than do women, and younger age-groups have higher rates of under-diagnosis. Overdiagnosis appears to be a problem among older age groups. These data indicate an urgent need to improve diagnosis of diabetes, particularly among the younger age-groups, and especially among men. Figure 34: Egypt – Diagnosis of Diabetes Cases, by Age and Gender, 2006 Egypt - Diagnosis of Diabetes Cases, by age and gender Percent of cases not diagnosed (or 100% overdiagnosed) 80% 60% % of cases not 40% diagnosed 20% (negative) 0% -20% % women not -40% diagnosed or -60% over-diagnosed -80% (positive) -100% 25-34 35-44 45-54 55-65 25-65 Age groups Source: 2006 Survey by Epidemiology and Disease Surveillance Unit of the Ministry of Health Source: Calculations made based on data from Egyptian Ministry of Health (2006), cited in World Bank mission report June 2008. The management of diabetes in Egypt is characterized by limited information sharing and coordination of care, and there are no national data about how diabetes is managed in Egypt, nor are there national clinical guidelines or clinical pathways to assist clinicians in managing diabetic patients. Although many individual practitioners are making an effort to improve the situation, in the absence of adequate information systems and national programs to coordinate health care, these individual efforts are inadequate. For example, very few patients have their long-term metabolic control assessed (as measured by glycosylated Hemoglobin HbA1c) even once per year. Such a measurement is essential for effective clinical management of diabetes. Reasons given for this vary from absence of laboratory capacity to carry out tests to insufficient health insurance coverage. In the Health Insurance Organization (HIO) clinic, where such tests are both covered and ‘mandated’ by HIO guidelines, it was not possible to find evidence of compliance with such guidelines. There is also a need for much greater attention to be given to patient education about how to manage their condition, including preventive foot care and dietary advice. The Step-Wise Survey of Non-Communicable Diseases, conducted by the Egyptian Ministry of Health in 2006, measured the self-reported complication rates among the persons diagnosed with diabetes. According to this survey, 21 percent of respondents reported “ocular complications� (12 99 percent of men and 28 percent of women), while 10 percent reported “foot complications� (8.7 percent of men and 11 percent of women). Since this survey included only patients who had been previously diagnosed with diabetes, and since diabetes is under-diagnosed as discussed above, it is likely that these reported complication rates are also significantly under-reported. In summary, evidence suggests that diabetes in Egypt is significantly under-diagnosed, particularly among young age-groups, and among men. Furthermore, available information suggests that both process and outcomes of diabetes care in Egypt is inadequate on a number of dimensions, resulting in a high level of complications. This in turn leads to higher cost of treatment and greater productivity losses, as well as excess levels of morbidity, mortality, and disability among this group of patients. Given the high rates of risk factors and the growing prevalence of diabetes, it is urgent for Egypt to implement a national diabetes program to address these existing shortcomings and to shift resources towards patient education and to strengthening the quality and effectiveness of primary care services with respect to diabetes case management. B. Measuring client satisfaction and quality of primary health care services in Alexandria and Menoufia Governorates, Egypt A health survey conducted in Egypt between April and December 2009††† offers an insight into the relationship between client satisfaction and quality of health care. This study included subjective assessments of patient satisfaction with technical quality measures, using a quality index based on structural observations of doctors. The survey included: (i) a facility survey covering all public health care facilities in the two Egyptian governorates of Alexandria and Menoufia, including questionnaires on service quality and management, and structured observations (real time, non vignette) of 8 consultations per facility; and (ii) a household survey of 5417 households living in the facilities’ catchment areas. With regard to patient satisfaction, patients rated all aspects of their visit to the health facilities positively with rates close to or over 90 percent. The same observation holds when the question is asked more generally and people are asked to rate their overall satisfaction with the last visit to a health facility; approval ratings are relatively high (Table 20). Table 20: Client rating of aspects of their last visit to health % of respondents Client opinion about… positive Waiting Time 88.4 Cost 92.9 Friendliness 96.6 Staff Qualification 96.6 Staff Availability 96.9 ††† The survey was conducted by the World Bank for the Ministry of Health of Egypt as part of the project completion evaluation of Egypt Health Sector Reform Program (1999-2009). 100 Comfort of waiting area 97 Location of Facility 95.9 Does this mean the people Alexandria and Menoufia receive outstanding quality of care? The answer has to be “probably not�, when looking at the quality index based on client observations for management of Diabetes Mellitus, Hypertension/Coronary Heart Disease (CHD), antenatal care, and sick child treatments. Based on the guidelines from the Ministry of Health (MOH), trained doctors observed a total of 5,040 provider/client interactions, looking at the adherence of physicians to basic elements of treatment of the respective health issues. For each of the four health interventions, information on adherence to protocols were compiled into a normalized index from 0 to 1, where 0 means none of the basic aspects of treatment were carried out and 1 that all aspects were carried out. Thus, a score over 0.5 means that the average provider carried out half of the procedures formulated in the guidelines. The results are summarized in Table 21, below, which provides the mean and standard deviations of the quality scores for the four different health issues. The score on the quality index varies from 0.375 for CHD/Hypertension consultations to 0.632 for antenatal care. In other words, for the average consultation of a hypertension patient, the provider carried out only one third of the procedures required according to the guidelines of the Ministry of Health. These scores indicate that there is considerable scope for improving the clinical quality of care, and this quality gap is more pronounced in the management of chronic diseases, such as diabetes and hypertension. These findings are consistent with the findings on diabetes treatment discussed in the previous section. Table 21: Egypt Health Care Quality Index, by governorates Alexandria Menoufia All Mean SD Mean SD Mean SD Antenatal 0.654* 0.112 0.623 0.129 0.632 0.126 Sick Child 0.596 0.142 0.582 0.15 0.582 0.147 Diabetes 0.448* 0.111 0.389 0.159 0.392 0.151 CHD/Hypertension 0.421* 0.12 0.341 0.155 0.375 0.164 *= Significantly different at 95% confidence level Table 22, below, summarizes the scores on patient satisfaction and clinical quality, by Governorates. It is interesting to note that the clinical quality does not necessarily correlate with patient satisfaction. The facilities in Menoufia governorate shows a higher patient satisfaction rate, but has a lower average score on quality of clinical care measured objectively by the specialists. Table 22: Summary of Patient Satisfaction Rates and Average Quality Scores, by Governorates 101 By Governorate Percentage of respondents Average Quality Score indicating “extremely satisfied� with last visit Alexandria 63.4% 0.411 Menoufia 81.2% 0.372 The results, presented in Figure 35, show the relationship between satisfaction rates and scores on quality index. Again, this shows little correlation between patient satisfaction and clinical quality of care, revealing the underlying information asymmetry which affects patient perception of quality. Figure 35: Egypt Clinical Quality Score vs. Patient Satisfaction Score in Primary Health Care Services, by Directorates in Alexandria and Menoufia Governorates, 2009 C. Improving the Quality and Efficiency of Hospital Services – A Tunisia Case Tunisia is a middle income country with a population of over 10 million. The Tunisian health sector has performed relatively well over the past decades, and Tunisians enjoy a relatively high life expectancy, estimated to be 74 years in 2007 and a low infant mortality at 21 deaths per 1,000 live births. A study undertaken by the World Bank in 2005‡‡‡ examined various aspects of the health system in Tunisia, including technical efficiency within the hospital system. That study found indications of a mismatch between the distribution of hospital beds and current patterns of inpatient service utilization. While the average bed occupancy rate in the teaching hospitals was 79.3 percent , with some hospitals recording as high as 102.5 percent occupancy rate, the average ‡‡‡ Republic of Tunisia Health Sector Study Report, the World Bank, 2005 102 occupancy rates for lower level hospitals remained very low, ranging from 36 percent for district hospitals to between 50 – 64 percent among regional hospitals. This pattern of hospital occupancy rate would suggest that beds are not allocated efficiently between levels of care, at least in regards to current medical practice, with some of the cases treated by university hospitals perhaps being more appropriately handled at lower levels of care, or be avoided altogether. For example, amputations of diabetic patients’ limbs are almost completely preventable if the patient care is managed well at the primary care level. Yet recent estimates in Tunisia indicate that approximately 75 percent of all amputations are to diabetics, suggesting poor diabetes management. To understand better the performance of the government healthcare providers, in 2008/2009 the Tunisian Ministry of Health, in collaboration with the World Bank, commissioned a report evaluating the quality and cost of four public hospitals, including a university hospital center, a regional hospital, a district hospital and a teaching hospital. The following section summarizes the main findings which are described in the report the “Performance of Tunisia’s Public Health Facilities�. Part of the study involved the assessment of cost differences and treatment modality differences between the various facilities. Two indicator pathologies - high risk pregnancies and coronary heart disease - were examined in detail for this purpose. The average cost of an episode of patient care for high risk pregnancies and coronary heart disease are summarized respectively in Table 23 and Table 24. Table 23: High Risk Pregnancies: average age of patients, length of stay and total cost of episode Total Cost of Episode Age of Length of Stay (Tunisia Patient (days) Dinars) University Hospital B 30.7 14.8 1,458 Regional Hospital 30.3 3.2 254 District Hospital 29.1 3.1 479 Overall Average 30.0 6.5 679 Table 24: Coronary Failures: average age of patients, length of stay and total cost of episode Total Cost of Average Episode Age of Average Length (Tunisia Patient of Stay (days) Dinars) University Hospital A 62.4 11.2 2917 University Hospital B 57.3 9.6 2752 Regional Hospital 59.2 8.9 800 Overall Average 59.5 9.8 2119 Source: University of Montreal. “Performance of Tunisia’s Public Health Facilities�. Study commissioned by the World Bank for the Government of Tunisia, 2009. In addition, the study developed a standardized treatment protocol for these two interventions, and estimated the total cost of episode if the full standard protocols were followed 103 within each hospital setting. These estimations are shown in Table 25, below. They show that actual treatment of coronary heart diseases in the university hospitals appear to be 15-20 percent below the cost of standardized treatment, and high risk pregnancies treated in the district hospital is 32 percent below the cost of standardized treatment. These figures suggest that these hospitals may be under-treating the patients or not following the standard protocols, an indication of potential problems with the quality of care. Alternatively, the providers suggested that this might also indicate that some of the costs of care are being cost-shifted to the patients, who are required to pay out-of-pocket to supplement the total cost of care, e.g., by purchasing medication and medical supplies which may not be available or out of stock at the hospital. This is supported by the results of the patient surveys which were carried out at the same time (see Error! Reference source not found.). The survey found that lack of harmaceuticals was reported as a serious problem by 64 percent of respondents in the district hospital, and lack of medical supplies was reported among 22 percent of respondents at the University Hospital A. Table 25: Estimated Cost for Therapeutic Standards vs. Observed Cost of Care, Tunisia For Coronary Failures Total Cost of Episode (Tunisia Statistics Dinar) University Standardized Cost 3,307 Hospital B Observed Cost 2,752 % standardized/ observed cost 120% University Standardized Cost 3,328 Hospital A Observed Cost 2,917 % standardized/ observed cost 115% For High Risk Pregnancies Total Cost of Episode (Tunisia Statistics Dinar) Standardized Cost 262 Regional Observed Cost 254 Hospital % standardized/ observed cost 103% Standardized Cost 633 District Observed Cost 479 Hospital % standardized/ observed cost 132% If these hospitals were required to follow the standard treatment protocols, and to fully finance the treatment and not cost-shift to patients, then the total cost of treatment will be expected to increase if the same utilization patterns at each of the hospitals were maintained. However, according to the clinicians working on site in University Hospitals A, it is estimated that about 30 percent of the patients could have been treated at a lower level of care, primarily in Regional 104 Hospitals with cardiology specialty. Given that the cost of episode at the sample Regional Hospital is less than 30 percent of the cost of care at a University Hospital, the potential for cost savings is significant. The relatively high unit cost of operations in the district hospital is another area for potential improvements. Since the unit costs were derived for each facility using its current operating expenses, it is likely that the high unit cost of the district hospital reflects its low utilization rate. But in order to have more patients make use of these district hospitals, it will be necessary to invest in improving the quality of care, including the availability of drugs. Overall, there is scope for the Ministry of Health to improve the quality of care (which would require additional resources) and improve efficiency at the same time, which would serve to contain costs. Figure 36: Patient Survey on Quality of Services in selected hospitals, Tunisia 2008 100 80 60 Poor Moderate 40 Good 20 Very Good 0 University University Regional District Hospital A Hospital B Hospital Hospital 80 Most common patient recommendations: 70 60 50 40 30 20 10 0 Hygiene Pharmaceutical Medical Supply Improve Patient Other Supply services, interaction, reception, patient planning hospitality University Hospital A University Hospital B Regional Hospital District Hospital D. Measuring Quality of Care - Patient Responsiveness In 2000, the WHO launched the Multi-country Survey Study on Health and Health System's Responsiveness (MCSS) in order to develop a consistent methodology for measuring health system responsiveness in the developing country context. The study involved 70 surveys conducted in 60 countries and used a common survey instrument in nationally representative populations, with modular structure for assessing the different domains of health system responsiveness. While 105 much work has been done on the measurement of patient satisfaction at health unit and country level, no internationally comparable survey instrument existed other than the work done by Donelan, Blendon et al (1996, 1998) in selected high income countries. As such, the WHO MCSS represents the first standardized responsiveness survey conducted in developing country context, and its objective, among others, was to determine the features and functions of the health system which enhance patient responsiveness. Responsiveness survey differs from patient satisfaction surveys in the following ways: First, the scope of patient satisfaction is usually limited to clinical interaction in a specific health care setting whereas responsiveness survey seeks to evaluate the health system as a whole. Secondly, the range of issues considered by patient satisfaction often combines both medical and non-medical aspects, but responsiveness survey focuses only on the non-medical aspects of the health system. Thirdly, while patient satisfaction represents a purely subjective perception of health care, responsiveness evaluates individuals’ experiences with the health system against a universally defined expectation of responsiveness. To this end, all questionnaires on responsiveness included vignettes designed to provide some measure of standardization in the evaluation process. Vignettes are short descriptions of hypothetical scenarios about people’s experiences with the health care system as they relate to the different domains of responsiveness. Respondents were asked to provide their rates applying the same rating scale used in the responsiveness description questions (“very good� to “very bad�). The seven domains of responsiveness, described below, were identified through literature and expert reviews, and were aimed at identifying dimensions reflecting respect shown toward patient rights and dimensions affecting patient perception of convenience and ease of use. Table 26: Domains of Health System Responsiveness – categories used in WHO Multi- Country Survey Study Domain Label The Question addresses: Dignity Respectful treatment Autonomy Involvement in decision making Confidentiality Confidentiality of personal information Communication Listening, enough time for questions, clear explanations Prompt attention Convenient travel, short waiting times Social Support In hospitals – visits allowed, having special foods, religious practice respected Quality of Basic Amenities Cleanliness, availability of space and air Choice Being able to use provider of your choice Figure 37: Health system responsiveness in selected MENA countries – for inpatient services, 2000/01 106 107 Figure 38: Health system responsiveness in selected MENA Countries for outpatient services, 2000-01 The results of the survey on inpatient and outpatient services in the MENA countries are respectively shown in and Figure 38. The average scores suggest that the higher income countries (Gulf Cooperation Countries) do relatively well, but higher income level and higher health care spending level is necessarily always correlated with better scores. However, the results of the Multi- Country Survey found that the respondents also gave higher importance to Promptness (40 percent), Dignity (19 percent) and Communication (19 percent). The appropriate weighting and interpretation of the responsiveness surveys will require further analysis and investigation on the reasons behind patient dissatisfaction with the services. A Key Informant Survey (KIS) containing similar responsiveness questions was launched at the same time in 35 countries (including Egypt and UAE). It was administered to “key informants� (e.g. providers, consumers, policy makers, media workers), who gave their opinions of their health system responsiveness of the public and private sectors. KIS found that the relationship between health care expenditure and dignity and confidentiality is very unclear, whereas some positive relationship was found between health care expenditures and prompt attention and quality of basic amenities.§§§ These trends suggest that a country's attainment with regard to responsiveness is not necessarily dependent only on the financial resources at its disposal. Even with limited resources, it may be possible for countries at lower income levels to achieve a higher level of patient responsiveness if appropriate incentives and support systems are in place. Improving health system responsiveness is expected to increase the confidence of the patients in health care and would be expected to contribute to increasing the use of services. §§§ De Silva, A., Valentine, N. (2001), “Measuring Responsiveness: Results of a Key Informants Survey in 35 Countries�, GPE Discussion Paper Series: No.21; WHO. 108 Whether this would lead to more efficient and appropriate use of services, for example, by encouraging patients to seek care early or improving compliance with treatment protocols, will require further investigations on the patient use of services. This point is highlighted by the additional survey undertaken by the MCSS, which asked respondents specifically for reasons they felt they were being treated badly by the health care provider (see Figure 39). These questions reveal yet another aspect of health system responsiveness: according to this survey, patients in the Gulf Cooperation states of Bahrain and UAE express higher levels of concerns regarding socio- economic discriminations than in the other MENA countries in the survey. Moroccan respondents report on very high rates of perceived discriminations due to social status and wealth. This is finding is consistent with the pervasiveness of informal payments that appear to affect access to healthcare at all levels of services in Morocco (unpublished report). Figure 39: Reasons for being treated badly by health service provider in selected MENA countries 109 E. Measuring Quality and Efficiency in the Pharmaceutical Sector Pharmaceutical spending represents a relatively significant share of health spending in most countries in the MENA region, ranging from 13% in Iran (which is likely to be an underestimation due to subsidized prices) to as high as 60% in Morocco (see Figure 40, below). There is a wide variation in the share of public and private spending on pharmaceuticals. For those countries where a significant portion of the pharmaceutical expenditures is incurred in the private sector, such as in Jordan, Morocco and Lebanon, where private sector prices are high while public sector availability is low, the households could face significant barriers to accessing affordable medicines. Figure 40: Pharmaceutical Spending in selected MENA countries, as a share of total health expenditure around 2000-2004. Pharmaceutical spending in selected MENA countres, as percent of total health expenditure 40 35 30 25 20 15 10 5 0 Private Public Total Sources: Data from The World Medicines Situation, World Health Organization (2004) for data from 2000, unless otherwise indicated below: Syria – Authors’ estimates based on 2004 Government statistics and household survey data provided in "Towards a Framework for Sustainble Health Financing in Syria", Detlef Schwefel, Health Sector Modernisation Programme (European Union Project) for the Ministry of Health of Syria, 2007. Yemen - Authors' estimation using 2005 Household Budget Survey and Government Public Expenditure data. Libya - Author's 2002/3 Libya household budget survey and Ministry of Health, Public Expenditure Review 2008/9. Note: * In Iran, pharmaceutical products (both locally produced and imported) are heavily subsidized. The spending figures shown here do not include the subsidized amount, and therefore probably underestimate the actual value of the pharmaceutical spending.**** **** See Cheraghali, A.M. “iran Pharmaceutical Market�, Iranian Journal of Pharmaceutical research (2006) 1: 1- 7; and The World Bank, Iran Health Sector Study, Volume 2 (2007): Washington DC. 110 Pharmaceutical Pricing. In this section the pharmaceutical pricing and costs in the MENA region are reviewed. The analysis is based primarily on the results of the relevant World Health Organization (WHO) and Health Action International (HAI) pharmaceutical pricing, affordability and availability surveys. The WHO/HAI methodology involves surveys being undertaken using a standard approach to measuring pharmaceutical prices. Specifically, the study examined a group of 30 medicines, with pre-set dosage forms, strengths and pack sizes that are relevant to the global burden of disease, with selected medicines of national importance. For each medicine the originator brand and the lowest price generic were identified in both public and private facilities. The WHO/HAI methodology presents prices as Median Price Ratio (MPR), which is defined as the local price divided by the international reference price (International Drug Price Indicator Guide converted to local currency). These reference prices were derived as the medians of recent prices by for-profit and not-for-profit international suppliers of generic products to developing countries. Thus, a “MPR� of 2 means that the local price is twice that of the international reference price. In addition, the WHO/HAI defined “Affordability� as the number of days an unskilled government worker would have to work to pay for a course of treatment for an acute condition, defined as one month’s treatment of a chronic condition. Figure 40, below, shows the information on public and private sector prices for the originator drugs and lowest price generics for the MENA countries where data were collected. Public sector prices for lowest price generics appear to be generally competitive, but for originator brands generally appears to be excessively high. Lower prices in the public sector are only of value if they are available to the population that needs them. It is evident that the private sector prices are high particularly for originator drugs, but the generic prices are also high. Figure 41: Relative drug prices in selected MENA countries, public and private sectors Relative price of drugs in the public sector Relative price of drugs in the private sector 20 20 18 18 16 Median Price Ratio 14 16 Median Price Ratio Originator 14 Originator 12 brand 12 brand 10 8 10 Lowest price Lowest price 6 8 generic generic 4 6 2 4 0 2 0 Note: 1. In the case of Jordan there are very few originator drugs sold in the public sector facilities, hence the MPR of 5.95 was for a single drug (Phenytoin), which cannot be regarded as a representative figure. Figure 42, below, shows the availability of pharmaceuticals in the public and private sectors. Under the WHO/HAI survey methodology the availability is based on the percentage of establishments where an individual medicine was found on the survey day. The results suggest that 111 availability of public sector drugs is very low, while availability in the private sector appears to be relatively high. Figure 42: Drug Availability in Public and Private Sectors, Selected MENA Countries Drug availability - % establishments with drugs available on the day of survey 100% PUBLIC Originator brand 80% 60% PUBLIC Lowest price generic 40% PRIVATE Originator brand 20% n/a 0% PRIVATE Lowest price generic From these data, it would appear that in the MENA countries where data were collected, the prices of pharmaceuticals obtained in the public sector appear to be relatively competitive, but their availability is low. By contrast, the prices in the private sector are much higher while the availability is generally more extensive. The consequence of these trends is that the patients who are eligible to receive drugs in the public sector may face shortages and are being obliged to seek them in the private sector. This is consistent with the findings that in most low and middle income MENA countries there is a high rate of direct household spending on healthcare, most of it on pharmaceuticals. Furthermore, there is some evidence of under-financing of Government funded services in a number of these countries, and that this might be contributing to inadequate supply of medicines and potential cost-shifting to patients who will be required to pay for them directly out- of-pocket. These findings show the importance of monitoring the use and prices of pharmaceuticals and investigate whether patients are not gaining access to necessary medications in the government-covered services and having to pay for these from private markets. There is also significant scope for improving efficiency and reducing the overall cost of healthcare by introducing more competitive pricing in the private market. F. Patient Safety in MENA In the MENA Region, an area that appears to have received relatively little attention is on Patient Safety. Box 1, below, provides a brief summary of the patient safety initiative in Saudi Arabia. Patient safety issues, including mitigation of medical errors, will likely become a major topic of interest as public awareness of medical safety issues become more prominent and more regularly reported. It will have important implications on the rights and responsibilities of patients and providers, and an essential aspect of health system responsiveness. Box 6: Patient Safety in Kingdom of Saudi Arabia 112 All health care systems have the potential to unintentionally harm the people they are trying to help through inappropriate decision and medical errors. Since the 1990s, a powerful body of scientific evidence analyzing the occurrence and impact of adverse events occurring world-wide has accumulated. Although there is much debate about the exact size of the problem, few would disagree that it is an important source of morbidity and mortality (Didier, 2005). As the research evidence has grown, an increasing number of countries have placed systematic action on patient safety on their political agenda as a policy priority. Since the 1999 publication of the Institute of Medicine's "To Err is Human: Building a Safer Health System," patient safety has become a critical area of focus for healthcare providers. This study shocked the US healthcare industry with the reported large number of near-misses and adverse events that threatened the health of patients in the US: according to the report, errors result in the deaths of 44,000 to 98,000 hospitalized patients and greater than 1 million injuries per year in the United States. In addition to the obvious negative impact on patient safety, medical errors also burden healthcare institutions with significant financial costs. In the US it is estimated that on average, one adverse drug event adds$2,000 or more to the total hospitalization cost. The total economic cost is even higher when one includes indirect costs such as reductions in employee productivity. Regulatory agencies and accreditation systems around the world have been developing and publishing a variety of mandates and recommendations to improve patient safety, and there is no shortage of guidelines and standards on this subject. However, healthcare providers face a challenge not only to keep up with the growing number of guidelines, but to find a supportive environment in which an open evaluation of their performance against such standards would not lead to sanctions or restrictions in the event of poor outcomes. In recent years, medical errors and adverse events have come under increasing media attention in Saudi Arabia, raising public awareness and concern with this issue. In response, a number of health care organizations in Saudi Arabia have initiated efforts to improve patient safety and quality of care through implementation of safety systems and to create a culture of safety (Al-Ahmadi, 2010a). A recent survey conducted in 13 general hospitals in Riyadh City, Saudi Arabia offers an insight into the state of patient safety in Saudi Arabia. The questionnaire contained mainly closed ended questions on several topics linked to leadership and safety culture. The total number of participants was 1200 hospital workers including: physicians, nurses, technicians, and managers. Results indicated an urgent need to improve leadership role in promoting safety in Saudi hospitals. Despite the fact that most respondents (74%) thought the actions of hospital management showed that patient safety is a top priority, a majority of respondents (51%) thought their hospital management seemed interested in patient safety only after the occurrence of an adverse event, and more than half of respondents (55%) thought that managers overlooked safety problems that occurred repeatedly (Al-Ahmadi, 2010a). It is recognized that efforts to reduce medical errors and adverse events are not effective in the absence of an environment which promotes open communication and supports continuous and constructive learning from errors. National initiatives are being proposed with these address these concerns, including: establishing the national focal point for patient safety, a national reporting system and adverse event notification, improving awareness on patient to patient safety, and set a national plan for continuous medical education (CME) and training for all personnel working in the health sector and in all aspects of patient safety. VII. Summary of Evidence and Next Steps Nationally representative information on quality and efficiency of healthcare is generally lacking in the MENA Region, and data related to quality and efficiency of healthcare are not collected on a routine basis or available for evaluating the performance of different segments of the health sector on a continuous basis. Where they do exist, they are generally collected as part of specialized surveys or studies, and offer only partial pictures of the health system performance. The absence of monitoring is itself an indication of inadequacies in the system, since healthcare requires continuous monitoring and evaluation in order to maintain a high level of healthcare and 113 to counteract the risks associated with information asymmetry and uncertainties in the sector. Due to the paucity of data on service utilization and quality, including cost of care, only a partial picture emerges as to the performance of healthcare in the region. The available evidence suggests the following issues: (i) Patient safety issues, while assumed to be part of the regular management and operations at the facility level, are not yet part of the national priorities in most MENA countries. Key indicators such as adverse drug effects, nosocomial infection, and other iatrogenic errors are not regularly monitored or publicly reported and the magnitude of the problem remains largely unknown. (ii) While most countries have introduced some standards for clinical guidelines and protocols, their application in evaluating the performance of the healthcare system remains limited. These efforts also appear to be fragmented by different specialities or disease groups, and few countries in the region have taken the initiative to prioritize the development of national guidelines based on epidemiological trends analysis, or to link their use with performance evaluation and payment or resource allocation mechanisms. (iii) Timeliness of care includes not only the waiting times at the point of service, but the patient access to early screening and treatment. There is evidence that chronic disease patients are not diagnosed in the early stages of the diseases, and enter healthcare only at the later stages of the disease when treatment becomes much more costly and prognosis poor. Many patients, especially among the lower income groups, may be foregoing care due to financial reasons or for other socio-cultural barriers to care: the implications of this foregone care on their burden of disease and subsequent social and economic conditions remain uncertain and warrant further examination. (iv) Most public sector healthcare providers do not have the capacity or the organizational structure to evaluate the actual cost of care (versus budget expenditures) for a service output or to compare the quality and appropriateness of the outputs against quality standards. Thus, neither the healthcare provider nor the payer are certain whether they are overpaying or under-financing services, or whether the healthcare providers are meeting the quality standards in the most efficient manner. There is also very little monitoring and evaluation of the efficiency and quality of care in the private sector. This is particularly notable in the pharmaceutical sector, where prices in the private sector in many MENA countries are significantly above international prices, and the use of generics is limited. Since a significant share of out-of-pocket health expenditure in the MENA region occurs for the purchase of pharmaceuticals, this has implications on people’s access to healthcare. (v) A number of countries are beginning to require healthcare providers to collect information on patient satisfaction and responsiveness. However, it is unclear how or whether this information is being used to influence the performance of the healthcare providers and to empower patients and improve their experience with the healthcare providers. What evidence there is suggests there is scope for significant improvements in quality and efficiency at all levels of care, and that the system may not be well prepared to deal with the expected rise in cost and complexity of healthcare in the near future. Based on the limited information, the following issues emerge as possible areas for future policy development and health system research in the MENA region: 114 Reorienting healthcare delivery system Changing roles of hospitals and primary care providers. In most MENA countries the primary care physicians do not act as gatekeepers to the health system, and by-passing of primary health care for hospital services is quite common. Low utilization at the primary care level – whether due to lack of knowledge among the patients or poor quality of services - leads to under-diagnosis and late identification of chronic conditions, and much more costly treatment at the higher hospital levels. This may reflect under-financing of services at the primary care levels, resulting in lack of human resources, poor supply chain management and overall poor quality of care at these levels. In some cases, this under-financing might lead to cost-shifting of expenses to the patients, which further discourages the use of services at these levels. In other cases, it may not be affordable or feasible to establish health facilities in every community, and a more affordable and feasible alternative solution is needed, such as the expansion of community outreach programs in lieu of fixed facilities. Case Management of Noncommunicable Diseases. In a number of MENA countries indications are that patients with NCDs are generally not followed up as regularly as needed and that many conditions are being detected late. Chronic diseases management require adherence to best practice and regular follow up, and are much more cost-effective as well as more effectively treated when detected early. The roles and resources of primary care services are variable throughout the region, but their capacities will need to be strengthened to ensure early detection and management of NCD cases as well as promotion of preventive care. Need for Quality Standards and Protocols. Most MENA countries have initiated the development of quality standards and protocols, but these tend to be undertaken separately and independently by different subsectors (ministry of health, social security administration, private sector, university hospitals) and there is as yet little or no coordination at the national level to identify priority needs or to ensure consistent standards across the subsectors. Moreover, these standards and protocols are not being used to inform resource allocation decisions, provide incentives to providers or identify quality shortcomings that may require additional training, capacity building or investments. Pricing and Costing of Healthcare Services and Goods. It is evident that substantial improvements are needed throughout the region on how services and goods are purchased and priced, and on how to monitor the actual cost of an episode of care. In most government-run services, the financial data are generally available only as expenditures by categories of inputs, and the system is not set up to allow estimation of actual costs by outputs, such as by episodes of care. These analyses require expensive, in-depth studies (e.g., Tunisia hospital study) in which the cost per episode of care have to be built up from the medical records as well as estimated production costs by each category of inputs. Thus, most government-run services are unable to provide timely estimates of costs of care by different categories of health service outputs (as opposed to inputs), which makes it impossible to monitor and compare how efficiently these services are being provided by different providers. There is also evidence of under-financing of services, in which part of the cost of services are shifted to patients, e.g., by having the patients purchase medicines and supplies or requiring informal payments to be made to health workers to augment staff income. Such practices not only obscure the actual cost of care as opposed to expenditures, but it severely undermines quality of care and patient trust in health services. Pharmaceutical pricing and appropriate prescribing practices. Optimizing the pricing and availability of pharmaceuticals in the MENA region is crucial as it can represent a large component 115 to the total health spending in the country, and represents a large share of out of pocket expenditures. In the MENA region, most governments are responsible for organizing the procurement of drugs for the public sector, and they are also responsible as for setting the price for drugs available in the private sector, such as agreements on the profit margin for the various participants in the supply chain. That the private sector is allowed to sell higher profit items, such as originator drugs, and not provide for lower cost generic drugs, raises questions about the primary objectives of the government pricing policies. Investing in Enabling Capacities and Tools Health Management Information System. In the majority of the MENA countries the process of gathering essential data and managing claims remains relatively basic, with most systems still being paper based. Although a number of initiatives are being planned or partially underway to introduce electronic health management information systems, the majority of these initiatives have yet to produce significant results. Healthcare services involve very large number of patient encounters with numerous interventions and permutations on the combination of interventions. If services are to be effectively monitored and continuously evaluated, then it is necessary that the required information is gathered and managed electronically, preferably directly from the source, such as the service providers. Paper based systems have a number of well-recognized weaknesses such as being prone to error, difficulty in consistently applying the rules, weaknesses in fraud and misuse detection, and difficulty in generating management reports. Such systems do not support the operation of effective utilization control measures. Establishing the Role of Independent Assessment Agencies in Promoting Quality and Efficiency. In recent years, there has been a rapid growth in the use of independent assessment agencies across the globe as a way of improving the quality of services provided by healthcare organizations in both developed and developing countries. This trend reflects the acknowledgement of the increasing complexity and dynamic nature of healthcare, and the inability of governments alone in regulating and assuring optimal performance at all levels of healthcare. The role of independent assessment agencies, such as accreditation organizations, food and drug authorities, and health technology assessment agencies, are growing in number and influence around the world to provide independent and professional assessment of various aspects of healthcare. A number of MENA countries are in the early stages of establishing such agencies within the context of the health system. There is considerable scope for such agencies to play a critical role in improving accountability in the health system, and in providing an independent and credible assessment of healthcare performance for both private and public sectors. Citizens empowerment and patient protection. Finally, and not the least, the role of patients as active participants in their own healthcare must be emphasized. While a number of initiatives have been started to measure patient satisfaction and health system responsiveness, it is not evident that the results of these findings are being applied effectively to influence policies or management practices. Programs to inform and educate the general public about prevention and health promotion could be significantly expanded, especially with respect to the new risks associated with NCDs as well as continuing this work to promote maternal and child health and nutrition in low income settings. There is also little public reporting on the performance of healthcare providers or on patient rights and responsibilities, and relatively little attention has been given to monitoring and enforcing patient safety. 116 The demographic and epidemiologic transition in MENA made it imperative that the performance of health systems will be measured in terms of how well they perform in managing chronic non communicable diseases. This means that it will no longer be sufficient to report on mortality alone as outcome, but also document all aspects of health-related quality of life in patients with chronic diseases, thus the importance of measuring technical and psycho social aspects of health care, its integration, coordination and responsiveness, together with patient satisfaction and re-designing the healthcare system in such a way so as to redefine professional leadership on care management, align incentives in the healthcare system and engage community and business leaders as effective partnership in healthcare (Ham, 2010). 117 Chapter 6. Creating Incentives for Better Results – Health Financing Reforms in MENA I. Regional Trends in Health Care Financing This section summarizes the trends in health financing indicators over the past 15 years, and reviews the extent to which the health financing systems of the countries have been performing, and what areas of strengths and weaknesses exist that will affect their performance in the coming decade. The key indicators are summarized in Table 27. Table 27: Key health financing indictors in the MENA region and the global averages by income groups, 2008 MENA Average Global Average Income Group: Health expenditure % GDP Low-income countries 3.76 5.72 Middle-income countries 5.63 6.21 High-income countries 2.84 7.52 Per capita health expenditure (US$ PPP) Low-income countries 46 31 Middle-income countries 211 273 High-income countries 1,162 3,066 Public spending on health as % total health expenditure Low-income countries 41 42 Middle-income countries 58 60 High-income countries 72 72 Public spending on health as % total Government expenditure Low-income countries 4.5 9.6 Middle-income countries 8.8 10.6 High-income countries 8.0 14.0 Private out-of-pocket as % total health expenditure Low-income countries 58.0 45.8 Middle-income countries 38.1 32.2 High-income countries 22.7 20.1 Source: WHO-WHOSIS National Health Accounts; accessed May 2010. See Statistical Annex for country level details. By comparing the trends in healthcare financing in MENA region with the global trends, the following salient features emerge. At all levels of income, the MENA countries have been spending a relatively smaller share of the economy on health (measured as a percentage of GDP). What is particular to the MENA region is that while the rest of the world has shown a significant increase in the level of spending on healthcare between 1995 and 2008 as a share of GDP at all levels of income (+11 percent increase among middle and high income countries and +43 percent increase among low income countries), the MENA countries on average have shown a relative decrease in health spending as a share of the total economy (-23 percent decrease in GCC countries, -1 percent decrease in MENA middle income countries, and -18 percent in Yemen). At the same time, the level of public spending on healthcare as a share of total government spending has been low relative to the rest of the world, while private out-of-pocket spending has been high. 118 Figure 43: Total Health Expenditure as % GDP in MENA countries, 1995 and 2008 Total Health Expenditure as % of GDP 12.0 10.0 9.1 8.5 8.8 8.0 6.0 6.3 6.2 5.7 6.0 5.3 % GDP 4.5 4.8 3.7 4.0 3.2 2.7 2.8 2.0 0.0 1995 2008 Total Health Expenditure as % of GDP 8.0 7.5 7.0 6.0 5.0 % GDP 4.0 3.3 3.3 3.6 3.0 2.4 2.4 1995 2.0 2.0 2008 1.0 0.0 Kuwait Oman UAE Qatar Saudi Bahrain High Arabia Income Average (a) It should be noted that there has been a real increase in per capita healthcare spending in the MENA Region. However, last decade was a period of relatively high GDP growth rates in the MENA Region: the overall rate of increase in health spending did not keep pace with the economic growth rates, resulting in an overall slight decline of health spending as a share of GDP. 119 (b) The share of public spending on healthcare as a percentage of total government expenditures in the MENA region is significantly lower than the global average. Among the low and middle income countries, Tunisia, Egypt, Morocco, Syria, Libya, Iraq and Yemen were significantly below the global average for their income group in 2008. On one hand, this would suggest that these governments have managed to contain costs and potentially delivered services efficiently. However, among these countries, Egypt, Morocco and Tunisia also showed significant increase in out-of-pocket spending as a share of total health spending. These trends would indicate that at least in these countries, the tight cost control over government spending on health care might in fact be leading to shifting an increasing share of healthcare costs to the patients. (c) In the MENA region, the share of out of pocket spending as a percentage of total health expenditures is relatively high when compared with the global averages. Over the last 15 years, there has been a small decline on average in the share of OOP spending. However, in a number of countries (Egypt, Morocco, Iran, Tunisia, Jordan and Yemen) the share of OOP is not only above the global average, but it has been increasing as a share of total health expenditure. As indicated above, this would suggest that the risk pooling mechanisms are not keeping pace with the rising demand for healthcare in these countries. Syria and Lebanon are also countries with OOP significantly above the global average, but the share of OOP has been declining over the past years. 120 Figure 44: Total Health Expenditure as % of GDP in MENA countries and Global Averages, 1995-2008 Total Health Expenditure as % of GDP 12.0 10.0 9.1 8.5 8.8 8.0 6.0 6.3 6.2 5.7 6.0 5.3 % GDP 4.5 4.8 3.7 4.0 3.2 2.7 2.8 2.0 0.0 1995 2008 Total Health Expenditure as % of GDP 8.0 7.5 7.0 6.0 5.0 % GDP 4.0 3.3 3.3 3.6 3.0 2.4 2.4 1995 2.0 2.0 2008 1.0 0.0 Kuwait Oman UAE Qatar Saudi Bahrain High Arabia Income Average 121 Figure 45: Per Capita Total Health Expenditure in Constant 1995 US$ for MENA Countries and Global Averages, 1995 - 2008 Per capita total health expenditure 600 551 500 383 Constant 1995 US$ 400 294 300 273 273 205 213 200 133 111 76 81 88 100 n/a 46 31 0 1995 2008 Per capita total health expenditure 3,500 3,066 3,000 2,704 Constant 1995 US$ 2,500 2,000 1,429 1,500 921 927 1995 1,000 572 2008 422 500 0 Oman Saudi Bahrain Kuwait UAE Qatar High Arabia Income Average 122 Figure 46: Public Spending on Healthcare as Share of Total Government Expenditure in MENA Countries and Global Averages, 1995-2008 Public spending on healthcare as a share of total Government expenditure 16.0 14.2 % total govenrment expenditure 14.0 12.4 11.4 11.4 12.0 10.7 10.6 9.6 10.0 8.9 8.0 7.1 6.2 6.0 6.0 5.4 4.5 4.0 3.1 2.0 0.0 1995 2008 Public spending on healthcare as a share of total Government expenditure 16.0 14.1 % total government expenditure 14.0 12.0 9.7 9.8 10.0 8.8 8.9 8.0 6.3 6.0 4.7 1995 4.0 2008 2.0 0.0 Oman Kuwait Saudi United Qatar Bahrain High Arabia Arab Income Emirates Average 123 Figure 47: Out of pocket spending as share of total health expenditure in Middle Income MENA Countries, 1995 – 2008 Out of pocket spending as share of total health expenditure 70 58.7 58.0 60 54.9 56.1 51.7 % total health expencditure 50 45.8 40.0 42.5 40 33.4 32.2 30 23.6 24.1 18.8 20 15.3 10 0 1995 2008 Out of pocket spending as share of total health expenditure 60.0 % total health expencditure 50.0 45.5 40.0 30.0 26.5 19.7 21.3 20.8 17.0 1995 20.0 2008 10.0 6.3 0.0 Saudi Oman Bahrain Kuwait Qatar UAE High Arabia Income Average 124 Table 28: Summary of Health Financing Trends over 1995-2008 and in comparison to Global Averages by Income Groups in 2008 Public Spending on Private Insurance Total Health Health as % OOP as % Total as % of Total Expenditure as % Government Health Private GDP Expenditure Expenditure Expenditure � vs. global � vs. global � vs. global � vs. global  average  average  average  average GCC Countries Bahrain - Low - Low - Average - Low Kuwait - Low +/- Low + Average - Low Oman - Low - Low + Low +/- High Qatar - Low + Low - High +/- None Saudi Arabia + Low + Low - Low + High UAE - Low + Low - High + High GCC Average - Low + Low - High + Average Middle Income Countries Algeria + Low + Average - Low + Low Egypt + Low + Low + High - Low Iran + Average + Average + High + Low Jordan + High - High + Average + Low Libya - Low - Low - Low 0 None Morocco + Low + Low + High - High Syria - Low - Low - High 0 None Tunisia - Average + Low + High - High Lebanon - High + High - High - High Djibouti + High + High - Low - Low Iraq + Low + Low - Low 0 Low Palestinian Territories n/a n/a n/a n/a n/a n/a n/a MENA MIC - Low + Low - High - Low Average Low Income Country Yemen - Low - Low - High - Low Note: “Low� refers to below the income group average for the indicator, “average� refers to those close to income group average; and “high� indicates above the income group average. 125 II. An Overview of the Health Financing Systems in the Region B. Predominance of Government-administered Healthcare Services The health systems of the MENA region are partly a reflection of the diversity of the Region itself. MENA countries rely on a broad range of approaches to mobilize resources for health and organize the delivery of services. Generally, the countries in the region have relied on government- run healthcare services to deliver a set of basic health benefits nominally guaranteed by the State. In most countries, the publicly funded or subsidized services continue to be delivered primarily through the traditional administrative system in which the health professionals are salaried public employees or government civil servants, and resources are allocated to the providers through a centralized annual budget process that focuses on factors of inputs and quantity. This form of hierarchical administration defines resource allocation in terms of historical supply rather than on strategic outcomes and quality of services. This approach limits the scope for engendering greater accountability on the part of the health care providers towards agreed performance criteria, and creating incentives to achieve better results for the beneficiaries. A number of countries are beginning to introduce reforms within the government financed healthcare systems to improve performance. For example, in Lebanon the Ministry of Public Health (MoPH) is taking the lead in allowing greater autonomy in public hospitals and introducing performance- based contracts with both public and private facilities. In the Palestinian Territories, the Palestinian Authority has recently introduced prospective contracts with selected private and nongovernmental healthcare providers to extend the coverage of subsidized services through these providers as well as through the public health facilities. In Egypt, the Ministry of Health has piloted performance-based payments on a limited basis through the pilot Family Health funds which covered integrated primary health care services in a few selected reform governorates. Morocco initiated autonomy in public hospitals a decade ago, but its implementation has been slow. Among the lower income countries, Djibouti in the process of introducing hospital autonomy in the Peltier Hospital, its main tertiary care hospital, but performance based payment systems have yet to introduced. The experiences within the Region will offer important lessons. The expansion strategic approaches to allocating resources and paying providers will constitute central components of health financing reform in the MENA region in the decade to come. G. Challenge of Expanding and Diversifying the Revenue Base for Health Most of the low and middle income MENA countries are facing severe fiscal constraints due to the substantial food and energy subsidies on which governments spend public funds (The World Bank, 2009). These fiscal constraints are not expected to be lifted soon, and therefore, there will be limited scope for financing the expansion of healthcare coverage through the general revenue base. Most low- and middle-income countries of the MENA region will need to identify alternative options to mobilize additional resources to meet the expected increase in the cost of, and demand for, health care as a result of the health transition, as discussed in the preceding sections. The high income GCC countries, in contrast to the low and middle income MENA countries, have relatively ample fiscal space to expand their expenditures on healthcare. Nevertheless, many of the GCC countries are seeking ways to diversify their revenue base for financing healthcare, especially for their large expatriate workforce, and to increase the contributions from employers and employees to the new health programs. This movement is part of the efforts by the GCC 126 Governments to move away from the welfare model and over-reliance on oil revenues towards greater social participation and social responsibilities by the population. A number of new health insurance schemes being developed and actively debated in the GCC countries involve some form of mandatory employer-employee contributions to cover new health plans. H. Expansion of Social Health Insurance Programs in the MENA Region Social security administered healthcare systems already play an important role in a number of MENA countries, including Morocco, Algeria and Tunisia, Egypt, Lebanon and Iran. However, the existence of large informal workforce and high unemployment rates is presenting a major obstacle to the expansion of these social insurance schemes beyond the current base of formal sector workers. Consequently, there is a continuing reliance on the government-run health care facilities to provide subsidized care for the uninsured population. The parallel existence of social insurance system and government subsidized healthcare system creates its own set of challenges. First, the availability of free or highly subsidized government healthcare reduces the motivation among informal sector workers to participate in a social insurance scheme. But closing access to subsidized government services can be politically difficult, and in the absence of a well-functioning social safety net system to target and exempt the poor and near-poor population, the closure of the subsidized system could result in excluding these vulnerable population groups altogether from accessing healthcare. Secondly, if the social security beneficiaries are also allowed to make use of the subsidized government health services, then a mechanism needs to be in place to ensure that the social security funds are charged for the cost of care. Otherwise, the government services will end up subsidizing those who are already covered under social insurance, and thus inadvertently transferring government subsidies for these categories of beneficiaries who are usually not the poorest nor the most vulnerable groups. Thirdly, it is possible that high risk patients, i.e. those who are the most seriously ill and likely to incur the highest cost of care, are encouraged to exit social insurance and avail of the government subsidized care, thereby shifting all the risks to the Government services which are already facing fiscal constraints. Finally, the existence of multiple health funds with different payment systems and coverage schemes significantly increases the administrative costs for both the payers and providers, and makes it more difficult to monitor and evaluate the quality and efficiency of services. Some countries have introduced measures to counter these issues in various ways. Lebanon has introduced a “visa� billing-system which undertakes eligibility checking of MoPH beneficiaries, excluding those who are already covered under other social insurance schemes. Furthermore, Lebanon is also initiating policy dialogue to harmonize the payment systems among the different social insurance schemes, including the Ministry of Health, in order to reduce the administrative costs, introduce greater transparency in measuring the performance of the providers, and reduce risk shifting across different plans. Tunisia has increased the reimbursement rate from the social security agency to the Ministry of Health for social security patients who are treated in government hospitals. However, the Tunisian Ministry of Health does not have the financial system in place that accurately estimates the actual production costs of treating patients. Tunisian public hospitals will need to develop capacities to evaluate its production costs and be able to demonstrate its ability to provide value for patients, especially in the face of the growing private sector. 127 I. Limited Role of the Private Sector in the Provision and Financing of Healthcare While the private healthcare providers and private health insurers have been expanding to some extent in a number of MENA countries, their growth has been relatively slow. In addition, many countries report that the private health markets are only partly or weakly regulated. As will be discussed in more detail below, the MENA region also has limited private insurance market, with preponderance of private spending still coming from direct household out-of-pocket spending at the point of services as was described above. In most MENA countries the regulatory environment for private health insurance market is weak, and insurance companies face many barriers to access. For example, in Egypt entry requirements for private health insurance is prohibitive for most companies (e.g., approximately US$5 million capitalization is required (see (Nassar & El-Saharty, 2010)), and the professional skills required to manage health insurance plans, such as medical actuaries, raters and underwriters, are lacking. There are exceptions, for example, Lebanon which has an active private health insurance market and companies that have developed considerable experience and skills in managing medical insurance plans. But in general this area remains underdeveloped in the low and middle income MENA countries. In the GCC countries, private health insurance markets are beginning to be tapped into as a means of extending mandatory employer-based insurance coverage. These initiatives are still in the early stages of design and implementation, and the further evolution of private health insurance markets in these countries remains to be seen. Given the limited availability and coverage by private health insurance, and lacking access to social health insurance or state-subsidized funds, the private healthcare providers in the MENA region face significant barriers to expansion, especially for services that involve high cost treatment and interventions. As noted above, some of the health reform initiatives in the region are expanding contracting of private providers by social insurance funds, but apart from Lebanon, the scope remains limited. A preponderance of private providers in the region are small-scale dispensaries and physician offices, many of which are run by public-sector physicians conducting private practice after hours. With the growth in income and demand for care among the population, there is an opportunity in the region to support a growing number of organized, large-scale private health care providers that could offer effective alternatives, or complements, to publicly administered healthcare system. Again, very few countries in the region explicitly include the private sector providers as an integral part of the national strategic plan to expand coverage and improve the performance of the healthcare system as a whole. These are potentially missed opportunities for engaging all the stakeholders in the sector towards the achievement of the national goal- that of ensuring access to and use of quality healthcare for all the population. III. Preparing the Health Financing Systems to Meet the Emerging Challenges of Health Transition in MENA This Report has demonstrated that the MENA countries face several critical health transitions over the coming decades. The demographic and epidemiological transitions will determine much of the health care needs as countries move from the current demographic profile of relatively young populations to one with a considerably larger share of middle-aged and elderly people. In parallel, the burden of disease is shifting toward more chronic non-communicable diseases and injuries and accidents. These transitions will put additional cost pressures on the health systems. Furthermore, the demand for more and more expensive health care will rise and 128 the supply of increasingly more sophisticated health technologies will also add to the health care costs. Compounding the situation is the limited fiscal space for health that many countries in the Region face. MENA countries will therefore need to identify alternative options for health financing in the years to come. Below is a brief discussion of some of those options and their particular advantages and risks, organized around mobilization of resources, organization of risk pools, and allocation of resources. A. Expanding the revenue base to meet the expected rise in demand for healthcare and expansion in supply of healthcare services With the advent of noncommunicable diseases and ageing effects on top of income growth, it is expected that the demand for healthcare will grow, and Governments in the Region will come under increasing pressure to expand the depth of the benefits covered under state-guaranteed health plan that will include a wider range of high cost medical interventions. At the same time most MENA countries will need to aim at reducing the share of direct out-of-pocket health spending by individuals and either organize them under some form of prepayment risk-pooling schemes or replace them with subsidies if they are poor or vulnerable. Given that most MENA low and middle income countries have very limited fiscal space to increase the fiscal allocation to cover these additional resource requirements, alternative options will need to be considered: (i) There are opportunities to organize at least part of the current relatively large out-of- pocket expenditures – which represent the household’s willingness to pay for services – into better organized risk pools. One option being considered by a number of countries in the region is to introduce new, or expand the existing, social health insurance schemes. However, this approach carries a number of risks, especially in most low and middle income MENA countries which have large unemployed and informal laborforce. A contributory social insurance system risks excluding from the risk pool the poor and unemployed who are unable to contribute, introducing distortions in the labor market, e.g., by discouraging workers from participating in the formal sector to avoid the additional tax on labor, and increasing administrative complexity by adding another level of organizational structure for collection and management of funds. (ii) Another option would be to improve the organization and regulation of the private health insurance market to enable households to direct their out-of-pocket spending on health into the purchase of a prepayment program. Some groups could be encouraged to purchase supplementary health insurance to provide coverage for services outside of the state-guaranteed benefits package. But this will require considerable investments in institutional capacity and regulatory systems in order to achieve effective results and avoid the risks of market failure, including adverse selection and moral hazard problems. (iii) There are also opportunities to broaden the revenue base for health through the introduction of taxes on certain goods and services that have a direct impact on public health. This could include tobacco excise taxes and VAT, which would have the effect of reducing the demand for tobacco. The revenues from this source could be applied towards subsidizing health care for priority public health programs (e.g., tobacco cessation program) and to subsidize priority population groups. In the MENA region, the current price of cigarettes inclusive of tax is extremely low, and other forms of tobacco (e.g., the use of shisha) are not taxed. Hence there is considerable scope for increasing revenues through this mechanism in the MENA region. 129 B. Improving the organization of risk pools for extending financial protection and health service coverage more efficiently This Report has shown that most countries in the Region have segmented health systems and multiple risk pools that operate independently from each other and with limited coordination or harmonization of rules across the different funds. This not only increases to the administrative complexity and overall cost of the health system, but also creates barriers for the citizens who must move across the different risk pools (e.g., moving from student status to informal employment , formal employment, and unemployment, and eventually to retirement) would benefit from ease of portability of benefits across these different categories. Lack of consistent or transparent rules and regulation among the different systems also complicates the task of monitoring and evaluating the performance of the different risk pools, and opens the system to influence by different interest groups whose objectives may not always coincide with the national goals of ensuring equitable, affordable and quality healthcare for all the citizens. A number of countries in region are beginning to take steps to address this issue. Tunisia recently integrated their two social insurance funds under a single social health insurance fund (conseil national d’assurance maladie - CNAM); Lebanon is taking an incremental approach to harmonizing the rules across the different social insurance funds including the Ministry of health; and Saudi Arabia has established a Council of Cooperative Health Insurance (CCHI) to coordinate and regulate the expansion of health insurance coverage for the expatriate workers through a multi-payer system. It is worth mentioning here that the parallel existence of social insurance system and government subsidized healthcare system creates its own special set of challenges. First, the availability of free or highly subsidized government healthcare reduces the motivation among workers to participate in a social insurance scheme. But closing access to subsidized government services for those covered under the social health insurance plan can be politically difficult to achieve. Secondly, if the social security beneficiaries are also allowed to make use of the government health services, then a mechanism needs to be in place to ensure that the social insurance funds are charged for the cost of care. Otherwise, the government services will be subsidizing those who are already covered under social insurance, and thus inadvertently transferring government subsidies to this group of beneficiaries who are less likely to be among the poor. Thirdly, it is possible that high-risk patients, i.e. those who are elderly or seriously ill are encouraged to exit social insurance and avail of the government subsidized care, thereby shifting all the risks to the Government services which are already facing fiscal constraints. Some countries have introduced measures to counter these issues in various ways. Lebanon has introduced a “visa� billing-system which undertakes eligibility checking of Ministry of Public Health beneficiaries, excluding those who are already covered under other social insurance schemes. Tunisia has also increased the reimbursement rates from the social insurance fund to the Ministry of Health for social insurance patients who are treated in government hospitals. However, the Tunisian Ministry of Health does not have the financial system in place that accurately estimates the actual production costs of treating patients and does not know how much of the patient costs they are subsidizing. Tunisian public hospitals will need to develop capacities to evaluate its production costs and be able to demonstrate its ability to provide value for patients, especially in the face of expected competition from the growing private sector. 130 C. Improving the value for money through strategic allocation of health resources and strategic purchasing of health services Most governments in the MENA region still operate through administrative, line-item budget process that focuses on limited categories of inputs (wages, operating expenses and capital investments), and which does not allow much scope for resource allocation based on performance. This also holds for the health sector, and there is evidence to suggest that this form of administrative structure and process is not effective at monitoring and detecting deficits in the performance of the healthcare services, or to take corrective action when they occur. International experiences show that allocating resources based on outcome and performance targets can have a large impact on the quality of health services, reduce unnecessary or wasteful use of services, and thereby add value for both patients by providers. Opportunities exist for most MENA countries to improve the performance of the health sector benefit by moving towards more strategic allocation of health resources within the existing envelope of resources. Against the expected substantial increase in the overall spending on healthcare in the coming decade, it will be even more critical to ensure that the capacities and mechanisms are in place to improve performance before further adding to the scope of services. Specific in this area include performance based commissioning and contracting for services, development of payment mechanisms based on case and episodes of care, and review and continuous evaluation of the benefits package based on needs and cost-effectiveness of interventions. In most MENA countries, the introduction of strategic allocation of resources and performance-based payment of providers would require changes to the budget formation and allocation process, as well as the way the civil service is managed and regulated. Given that such reforms often take time, the health system could introduce gradual changes to the way hospitals are run and providers are remunerated. An effective way to implement provider reform is by means of pilot projects that are well planned and implemented phases, and whose impacts are rigorously evaluated to provide guidance as to the further expansion of the payment and performance management reforms. Some countries have initiated changes in this area and but these need to be more sustained and scaled up, as the advent of noncommunicable diseases and technically more complex healthcare interventions will be introduced in the coming years. They will necessitate a much tighter and explicit control on costs and quality of care. In addition, introducing contracting would open up the possibility to create more efficient markets for health care where private providers can operate and provide the mandatory services along with public providers. This could potentially increase the supply of core services that can meet the increasing demand as incomes grow and disease patterns change. 131 Part 4. Meeting the Challenges – Charting the Way Forward Chapter 7: Building Partnerships for Results – Time for Strategic Action I. Window of Opportunity This report has highlighted the many impressive improvements in population health across the MENA region over the past decades. These achievements are due to many factors, including investments in education, water and sanitation, and broad access to basic health care for most citizens. The report has identified a number of critical areas of unfinished agenda and emerging challenges associated with the health transition which require urgent attention. A review of the performance of the existing health systems also reveals a number of systemic constraints that limit the nation’s capacity to respond effectively to these emerging health transition challenges. The MENA region has the window of opportunity to address these issues in the coming decade, during this period of “demographic dividend� while the population remains relatively young and not yet exhibiting the full effects of the health transition. Actions taken today will have the salutary effect of preventing premature mortality and morbidity in the future, and avoiding the high costs of treatment and long-term care of chronic conditions among the current cohort in the “youth bulge� which will shortly transition into “middle age bulge�. Table 29, below summarizes the nature of these risks by priority population groups Table 29: Major Risks Associated with Health Transition in the MENA Region, by Key Population Groups Population Groups/ Risk Risks Potential Impact Factors Children Irreversible damages due to Lower productivity– as much as undernutrition in terms of: 10 percent of the child’s future High rates of child malnutrition, earnings especially poor fetal growth or  lower achievements in stunting in the first 2 years of life, schooling, reduced adult Increased rates of micronutrient deficiencies income noncommunicable diseases during  higher risk of illness, including adult years Low birthweight non-communicable diseases Offspring born with low Increasing prevalence of  greater risk of low birthweight birthweight - inter-generational childhood obesity in offspring transfer of poor health risks Higher risk of non-communicable diseases among obese children 132 Population Groups/ Risk Risks Potential Impact Factors Youths Significantly higher risk of Rising cost of health care as the noncommunicable diseases among “youth bulge� transitions to Sedentary lifestyles and poor diet the current cohort of youths as “middle age bulge� leading to higher rates of obesity, they enter middle-age years physical inactivity Potential impact on future labor Potential bridging of HIV epidemic productivity due to expected rise Increasing prevalence of tobacco from high risk groups to general in disabilities rates among smoking population through youths working age population from Risky sexual behavior, exposure to noncommunicable diseases Increase in road traffic injuries substance abuse due to the growing size of youth Outbreak of HIV/AIDS epidemic to High exposure to road traffic cohort general population would fatalities and injuries substantially increase the cost of healthcare, reverse the gains in health outcomes, and raise the burden on the economy Increased burden on families and society and due to deaths and disabilities from road traffic injuries Women Women continue to face barriers Higher rates of avoidable mortality to access healthcare in a timely and morbidity among women and Persistence of social and manner – leading to late or their offspring due to: foregone or economic barriers to access to foregone treatment late access to healthcare; poor healthcare nutrition; and heightened risk of Poor nutrition among women of Malnutrition among women in noncommunicable diseases later child-bearing years leads to higher child-bearing years, especially in life health risks for both mothers and micronutrient deficiency and their children overweight Higher risk of non-communicable Very high rates of obesity among diseases due to higher rates of risk women factors, including obesity Increasing rates of tobacco Potentially higher risk of smoking among women HIV/AIDS transmission, due to lack of knowledge and information The MENA countries have the opportunity to develop programs in order to mitigate these risks, and to ensure that the next generation of children and youth will have the opportunity to participate fully in the social and economic life of their community. Table 30: Key Issues and Desirable Actions in the Health Sector in MENA Region Key Issues Desirable Actions 133 Key Issues Desirable Actions Mobilizing political support for Engage citizens, communities and business leaders in reducing population-based public health programs risks, promoting healthy lifestyles and safe environments (e.g. to mitigate key risk factors safe roads) Understanding and addressing socio- Encourage research in understanding social, including gender cultural barriers to healthcare and specific, aspects of health and health care, and implement healthy lifestyles social policies and programs Shift from hospital and specialist centered care which focus on treatment of patients only while they are within their facility, Reorienting healthcare towards greater to ‘patient-centered health care’ which gives attention to emphasis on primary prevention and continuity of care and the patient as a whole, both in and out of continuity of care healthcare setting. This will include empowerment of primary health care services to promote preventive care and patient case management Identify solutions, with the full engagement of the professional Enhancing professional accountability on groups, business community and civil society, in mitigating the quality of care and creating incentives risk of supply-induced demand and inappropriate, for quality and productivity unnecessary care; promote culture of continuous quality improvement and patient-centered approach. Ensure that expansion of healthcare coverage is closely linked Extending financial protection – making with social targeting mechanisms and social programs that strategic use of limited resources with help to direct subsidies to poor and near-poor and assure their priorities for the most vulnerable groups access to better care; and extend insurance coverage to non- poor Health system is a highly complex and dynamic sector, and that this will become increasingly so as MENA countries undergo epidemiological/demographic and economic transition. Due to the interactive and unpredictable nature of the sector, it will not be possible to identify a single blue-print solution to achieving high performance, and the traditional administrative system -- which had worked well so far in achieving relatively good health outcomes -- will no longer suffice to meet the emerging challenges. Rather, success will depend on countries setting up an effective institutional structure and processes that will enable different stakeholders to come together on a shared agenda: to agree on common goals, standards and actions, continually adapt to the changing needs of the population and demands created by new technologies, and be accountable to each other with respect to their own areas of responsibility and expertise. Delaying actions at this time will surely place all the good achievements of the past into jeopardy. II. Building Partnership for Results A major shortcomings of the past health policy reforms comprehensive approach to defining and measuring healthcare performance is the underlying assumption that the behavior of the healthcare system can be deterministically defined, and given sufficient details, made predictable. For many years, quality of healthcare has been defined along the model proposed by 134 Donabedian (Donabedian, 1978), in which healthcare performance is described and assessed in terms of structure, process and outcome indicators. This represents an “engineering� approach to finding an optimal solution, in which the system is deconstructed into a production process involving a well-defined set of inputs, outputs and technology. The approach has provided a valuable framework for assessing healthcare performance in a context where the services are well defined and provided in a well-controlled environment. However, there is an emerging consensus among many health policy analysts†††† who find that the performance of a highly complex and dynamic system such as healthcare cannot be adequately described using the engineering approach alone. They argue that this approach misses the important dimensions of multi-stakeholder perspectives and motivations that play such a fundamental role in decision-making in the health sector, and whose preferences do not always line up with the optimal “engineering� solutions. These behavioral dimensions are better captured in terms of inter-related models of accountability which identify and explicitly acknowledge the existence of these distinct - and often competing - interests and motivations among the multiple stakeholders in the system. The objective of this approach is to make the underlying motivations of the stakeholders more explicit, and allow the trade-offs among these competing interests to be conducted in a more transparent manner while holding each stakeholder accountable for carrying out their part in contributing to common goals. In healthcare, three models of accountability operate in a complementary manner and which play an important role in defining the varying perspectives and motivations of its key stakeholders. They consist of: (i) professional, (ii) economic, and (iii) social models of accountability (see Table 31). The “professional� model of accountability has historically played the dominant role in health care, based on the traditional view that the medical professional plays the leading, if not the sole, decision making role in determining the scope of services and ensuring quality of care. The medical professional groups (e.g., in the form of medical associations) are expected to establish and enforce self-regulation upon their own members who need to adhere to the minimum standards of practice in order to maintain their membership. †††† See the framework proposed by the Agency for Healthcare Research and Quality, described in “Identifying, Categorizing, and Evaluating Health Care Efficiency Measures,� prepared by Southern California Evidence-based Practice Center—RAND Corporation, Santa Monica, CA for AHRQ, April 2008. 135 Table 31: Models of accountability in healthcare setting Concept of Domain for “Beneficiary� action Mechanisms / instruments Professional Recipient of Professional Licensure, registration professional services associations and Certification, continuing education regulation Accreditation Economic Consumer of health Marketplace and Consumer choice and “exit� care services regulation Performance-based contracts, commissioning of services, or internal financial and non-financial incentives Pricing regulation (medical tariffs) Social Citizen receiving Patient engagement Public information and reporting on public goods and empowerment performance Consumer /patient Public health programs associations Enacting patient charters/ rights Community leadership Source: Adapted from (Leatherman, 2002). With the rising costs and complexity of healthcare, the professional model of accountability is no longer regarded as sufficient. There is a growing role of the state, the employers, the insurers, and other economic entities which increasingly play an active role in paying for healthcare, and these stakeholders have become important players in determining the scope of healthcare and demanding greater economic accountability in the health sector. The state would like to ensure that any public outlays are justifiable from political and social welfare perspectives, as well as fiscally affordable and sustainable. Employers and business leaders would like to minimize their exposure to financing the cost of healthcare for their workers, and insurers will want to maximize value for money and contain costs. From this perspective, the establishment of a health insurance system – in which “money follows the patient� – is often viewed as a way to introduce greater economic accountability into health care. However, this is not the only way in which economic accountability can be introduced. For example, the introduction of performance contracts by the Ministry of Health with autonomous public hospitals or with private or nonprofit health care providers is another pathway by which greater economic accountability and incentives can be introduced without necessarily creating a separate health insurance fund. Lebanese Ministry of Public Health and the Palestinian Authority are among those in the region taking initiatives in this direction. 136 Figure 48: Schematic diagram of the intersecting models of accountability in the health sector and the key stakeholders Economic model of accountability is predicated on the notion that competition, exercised through choice and exit by the consumer, can be an effective mechanism for enforcing accountability, particularly in ensuring an efficient allocation of resources. However, in healthcare it is well known that the sector is highly prone to market failure due to information asymmetry among providers, patients and insurers and uncertainties in treatment outcomes. For this reason, economic accountability will need to be balanced by professional accountability that will assure the quality and safety of healthcare services, since these dimensions of healthcare cannot be easily defined or perceived by the consumer through pricing mechanisms alone. The third model of accountability views the role of the citizen as beneficiary of “public good�, with the role of the state as one of compelling accountability through the instrument of “voice� and policy. The patient/beneficiary has been traditionally viewed as a passive recipient of health care. There is a growing appreciation for the role of the patients as an active participant and stakeholder in managing their own health as well as in making an effective and appropriate use of healthcare and in influencing their performance. Their good health and healthy lifestyles will also have externalities that go beyond the individual values: The patient may not necessarily perceive the clinical quality of care and therefore, will need to rely on professional accountability to ensure this aspect of healthcare. A beneficiary of health insurance plan or subsidized government health services will also not be aware of the full cost of providing care, and are liable to “moral hazard� – i.e., excessive or unnecessary use of health services. The patients also need to be protected from the poor quality care, which they will not be able to perceive or have the information to detect, but which could have detrimental effect on their health (e.g., adverse drug effects, hospital-acquired infections). For these models of accountability to function, there is a need for explicit measures of performance, supported by public reporting of these measures. As illustrated in Figure 48, the policy maker will have to address all three perspectives in designing health policies and programs. The introduction of economic and social accountability has been generally resisted by the health 137 professionals, who view these as an intrusion into their professional independence. Creating and maintaining an open and constructive dialogue among these competing interests is a significant and continuing challenge faced by health policy makers around the world. In the MENA region, the Ministries of Health have traditionally carried the primary responsibility for implementing public health programs and providing the basic healthcare services for the nation. This task can no longer be carried out effectively either through a single, centralized command-and-control management structure represented by the traditional role of the Ministry of Health or by leaving the process entirely to the market system. The task will require the development of a new, more diversified governance structure that will enable communities representing the key stakeholders to come together around shared goals, and where trade-offs among these groups are carried out in a constructive manner. Several recent reports have noted the absence of systematic data collection and public reporting on service performance in the MENA region (World Bank, 2009c). Among all the regions in the world, the MENA region has the lowest score (see Table 32) on “Voice and Accountability� (score of 18 out of 100). This paucity of data and public reporting also applies to nearly all dimensions of the health sector. There is a need for investing in surveillance systems for early detection and management of citizens with NCDs or with high risk of NCDs; obtaining timely and accurate reporting on road traffic accidents; or measuring and tracking different dimensions of malnutrition among mothers and children. There are very few sources of patient registry and quality and utilization assessments at the healthcare provider levels. These are of critical importance for the effective monitoring of the quality and cost-effectiveness of health service delivery and, importantly, for the introduction of strategic approaches to resource allocation or purchasing of health services. Table 32: Indicators of governance for MENA and Global, 2007 Voice and Political Government Regulatory Rule of Control of Accountability Stability Effectiveness Quality Law Corruption MENA 18 34 41 41 46 48 GCC 23 57 64 67 70 73 Non-GCC MENA 16 23 29 29 35 36 East Asia Pacific 34 44 47 44 43 37 Europe Central Asia 48 46 49 54 43 43 Lain America Caribbean 58 48 53 52 46 53 South Asia 26 25 35 31 34 32 Sub-Saharan Africa 33 34 27 28 28 31 High Income OECD 90 78 91 91 90 90 World 50 50 50 50 50 50 Source: World Bank Governance Matters Database. Note: Index values represent country’s placement in a worldwide distribution of countries based on that indicator, with 100 representing the country with the “best� governance, and 0 representing the country with the “worst� governance. 138 Good governance does matter, and have an impact on the ultimate outcomes. For example, within the MENA region, there is correlation between countries which have higher scores on quality of administration and health outcomes as well as access to basic healthcare (see Figure 49). Figure 49: Correlation between Health Sector Performance and Governance Indicator (Quality of Administration) in the MENA region Source: (The World Bank, 2003) III. Recommendations for Strategic Action An ounce of prevention is better than a pound of cure: promoting primary prevention through intersectoral action and primary health care A healthy transition from the Youth bulge to Adult age bulge is imperative for MENA countries if they are to maximize their social and economic gains from the demographic dividend and generate wealth. Health systems have a major role to play in this regard, not only through the provision of quality health services, but and perhaps equally importantly through a well conceived vision, strategy and public policies. Primary prevention, the avoidance or mitigation of the occurrence and incidence of a disease, plays a very important, if not primordial, role in this regard. There are really two sides to the coin of primary prevention in anticipation of the emerging NCD epidemic: (i) through healthy intersectoral public policies aiming at promoting population health, aiming at the four behavioral risk factors, namely smoking, physical inactivity, inappropriate diet (including both under nutrition and obesity) and risky driving: and (ii) through interventions aiming at improving 139 health of the individuals, namely, screening, counseling and primary care services to advocate for behavioral change. Primary prevention is not always less costly, if health benefits as measured in terms of quality adjusted life years (QALYs) are assessed against direct (health care) costs. About 20 percent of some 300 preventive interventions are considered to save costs in the long run. However, primary prevention is almost always cost effective, especially it is well targeted to high risk population groups and if indirect costs due to loss of productivity are also accounted for. MENA countries are well positioned to advocate for primary prevention for a number of reasons. The literacy rates are high for mass scale public information education and communication (IEC) programs, and the region has relatively good media coverage. School enrollment rates are high for targeted interventions on tobacco control, diet and nutrition. Institutional capacity for improved road safety is existent. And health systems are relatively well endowed for primary prevention in primary care setting. The challenges therefore is more about leadership in setting the right vision and strategies for effective advocacy for healthier public policies and gradual transformation of health systems to make them more attuned to providing primary care. Linking priority public health programs and the expansion of health coverage for the vulnerable population A number of countries in the region are beginning to address the need to improve the social targeting mechanisms and ensure a more effective allocation of subsidies. As these subsidy reforms are introduced and implemented, it would be important to ensure that the priority health policies and programs are explicitly included as the recipients of these additional resources. This will require strong justifications in terms of the cost-effectiveness of the interventions and the long- term benefits in terms of economic impact and social welfare gains that will accrue as a result of investing in these health policies and programs. Among the priority programs that should be in this list would include funds to subsidize access to basic health coverage for the poor and the near- poor, as well as public health programs that will promote healthy lifestyles and prevent health risks. It should be emphasized that social targeting on its own - while necessary - will not be sufficient for achieving behavioral changes on the part of both the beneficiaries and healthcare providers. The actual availability of services in the under-served areas and the appropriate use of healthcare services by under-served population groups will require an active program of incentives to the providers to be responsive to patient needs and preferences, and empowerment of the citizens. Expanding the revenue base and improving risk pooling to meet the expected rise in demand for healthcare With the advent of noncommunicable diseases and ageing effects on top of income growth, it is expected that the demand for healthcare will grow, and Governments in the Region will come under increasing pressure to broaden the benefits covered under state-guaranteed health plan to include a wider range of high cost medical interventions. At the same time most MENA countries will need to aim at reducing the share of direct out-of-pocket health spending by individuals and either organize them under some form of prepayment risk-pooling schemes or replace them with subsidies if they are poor or vulnerable. Given that most MENA low and middle income countries have very limited fiscal space to increase the fiscal allocation to cover these additional resource requirements, alternative options will need to be considered: (i) There are opportunities to organize at least part of the current relatively large out-of- pocket expenditures – which represent the household’s willingness to pay for services – 140 into better organized risk pools. One option being considered by a number of countries in the region is to introduce new, or expand the existing, social health insurance schemes. However, this approach carries a number of risks, especially in most low and middle income MENA countries which have many unemployed and informal labor markets. A contributory social insurance system risks excluding from the risk pool the poor and unemployed who are unable to contribute, introducing distortions in the labor market, e.g., by discouraging workers from participating in the formal sector to avoid the additional tax on labor, and increasing administrative complexity by adding another level of organizational structure for collection and management of funds. (ii) Another option would be to improve the organization and regulation of the private health insurance market to enable households to direct their out-of-pocket spending on health into the purchase of a prepayment program. Some groups could be encouraged to purchase supplementary health insurance to provide coverage for services outside of the state-guaranteed benefits package. But this will require considerable investments in institutional capacity and regulatory systems in order to achieve effective results and avoid the risks of market failure, including adverse selection and moral hazard problems. (iii) There are also opportunities to broaden the revenue base for health through the introduction of taxes on certain goods and services that have a direct impact on public health. This could include tobacco excise taxes and VAT, which would have the effect of reducing the demand for tobacco. The revenues from this source could be applied towards subsidizing health care for priority public health programs (e.g., tobacco cessation program) and to subsidize priority population groups. In the MENA region, the current price of cigarettes inclusive of tax is extremely low, and other forms of tobacco (e.g., the use of shisha) are not taxed. The exact scope for increasing revenues through this mechanism in the MENA region needs to be assessed in each country and given the cost-effectiveness of tobacco excise taxes, it is recommended that this is done across the region. Furthermore, the Report has shown that most countries in the Region have segmented health systems and multiple risk pools that operate independently from each other and with limited coordination or harmonization of rules across the different funds. This not only increases the administrative complexity and overall cost of the health system, but also creates barriers for the citizens who must move across the different risk pools (e.g., moving from student status to informal employment, formal employment, and unemployment, and eventually to retirement). These groups would benefit from ease of portability of benefits across the different categories. Introduction of consistent and transparent rules and regulation across the different health funds or health subsystems will facilitate the monitoring and evaluation of the performance among these different risk pools, and ensure their contributions towards the national goals of ensuring equitable, affordable and quality healthcare for all the citizens. Improving quality of care – engaging the professionals in the continuous quality improvement process and creating incentives towards patient-centered care Most governments in the MENA region still operate through an administrative, line-item budget process that focuses on limited categories of inputs (wages, operating expenses and capital investments), and which does not allow much scope for resource allocation based on performance. This also holds for the health sector, and there is evidence to suggest that this form of administrative structure and process is not effective at monitoring and detecting deficits in the performance of the healthcare services, or to take corrective action when they occur. International 141 experiences show that allocating resources based on outcome and performance targets can have a large impact on the quality of health services, reduce unnecessary or wasteful use of services, and thereby add value for both patients and providers. Opportunities exist for most MENA countries to improve the performance of the health sector benefit by moving towards more strategic allocation of health resources within the existing envelope of resources. Against the expected substantial increase in the overall spending on healthcare in the coming decade, it will be even more critical to ensure that the capacities and mechanisms are in place to improve performance before adding to the scope of services. Specifically, this will involve the introduction of performance based payments or contracting of services, either with private providers, or through internal allocation of resources within the public sector. Paying providers based on performance will require changes to the way the civil service is managed and regulated in many countries. Furthermore, introducing contracting would open up the possibility to create more efficient markets for health care where private providers can operate and provide the state-financed services along with public providers. This could potentially increase the supply of core services that can meet the increasing demand as incomes grow and disease patterns change. The complexity and dynamic nature of healthcare will be accelerated by the advent of noncommunicable diseases and the growing demand for greater choice and access to high- technology healthcare. In the middle and high income countries around the world, there is a growing trend towards the establishment of independent assessment agencies as a way of independently monitoring and evaluating the quality of services provided by healthcare organizations. Examples of such agencies include accreditation organizations, food and drug authorities, and health technology assessment agencies. These types of agencies are growing in number and influence around the world and they provide valuable professional assessments of various aspects of healthcare. The governance structure of these entities will be critical: ensuring a balanced representation of stakeholders will make certain the credibility and independence of these agencies. Such agencies can play a critical part in enhancing accountability, by developing locally adapted performance standards, benchmarking health care providers against these agreed standards, and providing educational support for the professionals operations. A number of countries in the MENA region are beginning to initiate the establishment of such organizations, for example, accreditation agencies and food and drug authorities, but the process may need to be accelerated. Strengthening Health Intelligence for sound decision making and evidence based partnership Timely and accurate information is a necessary, although not always sufficient condition for sound decisions. This is all the more critical in pluralistic health care systems to function effectively where market conditions are not always ideal and that there usually is a asymmetry of information among its multiplicity of partners. Policy makers, healthcare managers, health insurance fund holders, and the patients need to assess how well the healthcare system is performing, what are its strengths and weaknesses, and what actions need to be taken to address deficits in performance. This will require a fundamental shift from the traditional approaches to health information systems, which invariably focus on inputs to account for the budget, payroll, infrastructure, consumables towards a more user friendly, timely and relevant information system on service use in all its facets (volume, intensity, distribution, mix, technical quality, appropriateness, timeliness etc) and on patient health outcomes. Moreover, data would have to be aggregated or dis-aggregated (e.g., region, hospitals, primary care, diabetic patients, etc) in 142 accordance with the needs and demands of various partners. In addition, there is a growing need for population based information as a result of increased concern for global health security (e.g., Avian influenza, H1N1 etc). Finally, it is equally important to gauge the health status of the populations through periodic and issue-specific (e.g. nutrition, maternal health, etc) surveys to complement the information base and triangulate administrative data with primary data for drawing a better and more accurate and precise picture of the health, use of health services, and health system performance. A modern health management information system will enable managers to undertake concurrent review and assessment of the service performance, and allow better control and timely decisions over clinical management process (for managers of health facilities), the healthcare financing process (for healthcare payers), and public health reporting (for surveillance and other public reporting requirements such as international health regulations). Investments in these tools, both in infostructure (hardware) and the institutional and human capacity to collect, compile, synthetize, report and interpret the information (software) for decision making at all levels of care will be vital for improving accountability in the system and evaluating performance on a continuous basis. IV. Building Partnership for Results – Time for Strategic Action This report has highlighted the many impressive improvements in population health across the MENA region over the past decades. These achievements are due to many factors, including investments in education, water and sanitation, and broad access to basic health care for most citizens. At the same time, it identified a number of critical areas of unfinished agenda and emerging challenges associated with the health transition that warrant attention by policy makers and other stakeholders. The MENA region has the window of opportunity to take strategic action now, during this period of “demographic opportunity�, while the population is relatively young and healthy and the risks can be modified or averted. Actions taken today will have the salutary effect of preventing premature mortality and morbidity in the future, thus avoiding the future costs of treatment and long-term care of chronic conditions. This will require foresight and committed leadership at all levels of the society, and a greater understanding of the underlying causes of the risk factors in the MENA context. The rise in the prevalence of many of the risk factors can be traced to behavioral consequences of a multiplicity of causes: increased international trade (e.g., access to tobacco products, processed foods), migration (urbanization and sedentary lifestyle), changes in living conditions (e.g., sedentary work and living environment) and in the production, marketing and availability of goods (e.g., processed food). Potential solutions are bound to be context specific, but in all cases it will require partnerships among the key stakeholders: policy makers, professionals, business leaders, communities and the public. Success will depend on countries setting up effective institutional structures and processes that will enable different stakeholders to come together on a shared agenda: to agree on common goals, standards and actions, continually adapt to the changing needs of the population and demands created by new technologies, and be accountable to each other with respect to their own areas of responsibility and expertise. Delaying actions at this time will surely place the well-being of the next generation of children and youth into jeopardy. The time for strategic action is now to ensure that they will have the opportunity to participate fully in the social and economic life of their community. 143 Table 33: Summary of Recommendations: Policy Goals, Meeting Challenges and Forging Partnerships Policy Goals Meeting the Challenges Forging Partnerships Raise public Raise public support for and mobilize Forge new partnerships with media, awareness political leadership to support preventive civil society, business leaders, political health leaders. Enhance economic Link expansion of priority public health Engage Ministries of Finance, and fiscal programs and health coverage with Commerce, Social Affairs, Labor sustainability ongoing national strategies on subsidy and social safety net reforms; include strategic public health programs for priority investment Mitigate health risks Ensure that expansion of healthcare Engage Ministries of Finance, risks of poverty and coverage is closely linked with social Commerce, Social Affairs, Labor extend social targeting mechanisms and social programs protection for health that help to direct subsidies to poor and near-poor and assure their access to better care; and extend insurance coverage to non-poor Mitigate risk factors Improve the knowledge and understanding Undertake behavioral research with of the socio-cultural and environmental social scientists and design public factors that affect behavior and exposure to health programs that affect behavior; health risks, and develop effective social design safe roads with transport policies and programs that have impact. engineers; monitor progress with interested stakeholders Engage Ministries of Education, Agriculture, Industry, Commerce, Interior Mobilize business and Foster Corporate Social Responsibility Promote private-public partnerships, community leaders to towards safe and healthy work engage local community organizations support public health environment and healthy school and NGOs goals environment; expand community outreach programs Reorient health Create incentives for preventive primary Engage medical schools, professional systems care among health professionals and associations, health insurers/payers. promote patient-centered care; instill culture of continuous quality improvement and greater accountability on health care performance. 144 Annex 1: World Bank Classification of Countries Table 34: World Bank Group Classification of MENA Countries, by income levels Middle Income Countries High Income Countries (GNI per capita between US$976 and US$11,905 in 2008) (GNI per capita above US$11,906 in 2008) Algeria Members of the Gulf Cooperation Council Djibouti (IDA eligible/a) Bahrain Egypt, Arab Republic Kuwait Iran, Islamic Republic Oman Iraq Qatar Jordan, Hashemite Kingdom Saudi Arabia, Kingdom of Lebanon United Arab Emirates Libya, Arab Jamahiriya Morocco Syria Tunisia Low Income Countries (GNI per capita below US$975 in 2008) Yemen (IDA eligible/a) Note. a. IDA eligible countries are those that had a GNI per capita in 2008 of less than $1,135 and lack the financial ability to borrow the World Bank’s IBRD (non-concessional) loans. 145 Annex 2: Health Data for Chapter 1 – Maternal and Child Health Table 35: Progress on Millennium Development Goal for Reducing Under-5 Mortality Rates per 1,000 live births, for MENA Countries Annual Estimated U5MR in 2015 if rate of MDG same annual rate U5MR target of change reduction for maintained as between 1980 1990 2000 2010 2015 1990-2010 1990-2010 Non-GCC MENA Countries Algeria 100.9 52.4 34.1 19.3 17 15 -5.1% Egypt 157.9 85.4 45.6 24.7 28 18 -6.4% Djibouti 111.3 110 89.6 66.7 37 59 -2.5% Iran 107.2 65.5 46.7 31.1 22 26 -3.8% Iraq 78.2 58.4 42.7 31.6 19 27 -3.1% Jordan 54.4 33.4 23.7 14.1 11 11 -4.4% Lebanon 43.4 31.4 13.8 10.2 10 8 -5.8% Libya 61.8 37.6 22.1 12.9 13 10 -5.5% Morocco 124 76.9 50.5 32.4 26 26 -4.4% Palestinian Territory 70.6 41.9 29.3 22.1 14 19 -3.3% Syria 48.2 31.8 18.8 11.4 11 9 -5.3% Tunisia 80.7 47.4 27.2 15.2 16 11 -5.9% Yemen 188.1 128.3 93.2 60 43 49 -3.9% GCC countries Bahrain 29.6 19 12.2 7.4 6 6 -4.8% Kuwait 35 12.8 12.4 7.8 4 7 -2.5% Oman 97.6 37.1 15.9 9.3 12 6 -7.2% Qatar 27.5 15.9 12.8 10.5 5 9 -2.1% Saudi Arabia 71.9 29.5 21.8 15 10 13 -3.4% United Arab Emirates 38.1 16.1 7 3 5 2 -8.8% Source: (Rajaratnam, et al., 2010) Notes: a. Under-5 mortality rates were estimated using available sources, including vital registration systems summary birth histories in censues and surveys, and complete birth histories. Gaussian process regression was used to generate estimates of the probability of death between birth and age 5 years (see Source for details). 146 Table 36: Trends in Maternal Mortality Ratio/a per 100,000 live births in MENA Countries from 1980-2015 and Millennium Development Goal targets Estimated MMR in 2015 if same Average MDG average annual Annual target rate of reduction Rate of for maintained as Reduction 1980 1990 2000 2008 2015 1990-2008/b (in %) Non-GCC MENA Countries Algeria 396 189 94 66 47 43 -6.0% Egypt 352 195 74 43 49 23 -8.8% Djibouti 641 607 565 462 152 415 -1.5% Iran 101 64 35 28 16 20 -4.7% Iraq 241 212 174 130 53 107 -2.8% Jordan 214 103 59 35 26 22 -6.2% Lebanon 124 76 37 24 19 15 -6.6% Libya 148 124 63 40 31 25 -6.5% Morocco 601 384 262 124 96 78 -6.5% Palestinian Territory 181 92 52 46 23 35 -3.9% Syria 251 156 67 50 39 31 -6.5% Tunisia 294 141 56 36 35 20 -7.9% Yemen 808 582 383 269 146 197 -4.4% GCC countries Bahrain 132 89 49 36 22 25 -5.2% Kuwait 51 48 31 26 12 20 -3.5% Oman 174 85 41 24 21 14 -7.3% Qatar 52 49 26 14 12 8 -7.2% Saudi Arabia 135 94 47 28 24 17 -7.0% United Arab Emirates 41 31 14 9 8 5 -7.1% Source: (Hogan, et al., 2010). Countries are “on track� to meet the MDG 5 Goal of reducing MMR by 75 percent between 1990- 2015 if they reach an average annual rate of change at or below - 5.5 percent. Notes: a. Maternal mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births. The MMR data were estimated by Hogan et al., with a regression model using information on total fertility rate (TFR), gross domestic product (GDP)per capita, HIV seroprevalence, neonatal mortality, age-specific female education, and indicators for 5-year age-groups (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, and 45–49 years). 147 Table 37: Total Fertility Rates (births per woman), MENA Countries 1970 - 2008 YEAR 1970 1980 1985 1990 1995 2000 2006 2008 Non-GCC MENA Algeria 7.4 6.8 5.8 4.6 3.4 2.7 2.4 2.4 Djibouti 7.4 6.7 6.5 6.1 5.4 4.8 4.1 3.9 Egypt, Arab Rep. 6.1 5.4 5.0 4.3 3.7 3.3 2.9 2.9 Iran, Islamic Rep. 6.6 6.6 6.0 4.8 3.3 2.3 2.1 1.8 Iraq 7.2 6.5 6.2 5.9 5.5 .. 4.2 4.1 Jordan 7.9 7.0 6.2 5.4 4.6 3.8 3.6 3.5 Lebanon 5.0 4.1 3.5 3.1 2.8 2.5 1.9 1.9 Libya 7.5 7.3 6.3 4.7 3.7 3.2 2.8 2.7 Morocco 7.0 5.6 4.8 4.0 3.3 2.6 2.4 2.4 Syria 7.6 7.3 6.6 5.4 4.4 3.7 3.4 3.3 Tunisia 6.4 5.2 4.3 3.5 2.7 2.1 2.0 2.1 Palestinian Terr. .. .. .. .. 5.8 5.1 5.3 5.0 Yemen, Rep. 8.6 8.7 8.5 8.0 7.1 6.3 5.5 5.2 Non GCC AVERAGE 6.8 6.3 5.7 4.8 3.9 3.3 3.0 2.8 GCC Countries Bahrain 6.4 4.9 4.3 3.6 3.0 2.6 2.3 2.3 Kuwait 7.1 5.3 4.3 3.5 2.9 2.6 2.2 2.2 Oman 7.2 7.2 7.0 6.5 5.6 4.3 3.1 3.1 Qatar 6.8 5.7 5.0 4.3 3.7 3.1 2.6 2.4 Saudi Arabia 7.3 7.1 6.6 5.9 5.0 4.1 3.3 3.1 U.A.E. 6.5 5.4 5.0 4.3 3.4 3.0 2.1 1.9 GCC AVERAGE 7.2 6.8 6.2 5.5 3.9 3.9 3.1 3.0 Source: World Development Indicators, The World Bank, 2010. 148 Table 38: Health Inequities by Place of Residence and Income Quintiles, MENA Region Births Attended by Skilled Health Personnel Under-five mortality rate (probability of (%) dying by age 5 per 1,000 live births Place of Residence Income Quintile Place of Residence Income Quintile highest/ lowest/ highest urban/ lowest Urban Urban urban rural/ Rural Rural rural Highest Highest Lowest Lowest Country Year Algeria n/a n/a n/a n/a Djibouti 2006 40 95 2.4 89 98 1.1 73 95 1.3 n/a Egypt 2008 72 90 1.3 55 97 1.8 36 29 1.2 49.0 19.0 2.6 Iran, Islamic Republic n/a n/a n/a n/a Iraq 2006 78 95 1.2 n/a 41 41 1.0 n/a Jordan 2007 99 99 1.0 98 100 1.0 43 30 1.4 n/a Lebanon n/a n/a n/a n/a Libya Arab Jamahiriya n/a n/a n/a n/a 2003/ Morocco 4 40 85 2.1 30 95 3.2 69 38 1.8 78.0 26.0 3.0 Palestinian Territories n/a n/a n/a n/a Syria 2006 88 98 1.1 78 99 1.3 24 19 1.3 22.0 20.0 1.1 Tunisia n/a n/a n/a n/a 118. Yemen 2006 26 62 2.4 17 74 4.4 86 57 1.5 0 37.0 3.2 Source: Table 8, World Health Statistics, 2010 (World Health Organization, 2010b). 149 Annex 3: Population Pyramids for MENA Countries, 2009 and 2030 150 151 152 Population Pyramids for GCC Countries 153 154 Annex 4: Data and Background for Child Malnutrition Box 7: Glossary of Technical Terms for Nutrition Anemia: defined according to a hemoglobin < 110g/L, as reported inWHO Worldwide Prevalence of Anemia 1993-2005: a Global Database on Anemia. Low birthweight: a birth weight less than 2500 g. Malnutrition: A broad term commonly used as an alternative to undernutrition, but technically it includes both undernutrition and overnutrition. Obesity: In adults: a Body Mass Index >30 kg/m2. Overweight: In children: a weight-for-age of +2 z scores or more above the 2006 WHO Child Growth Standards. In adults: a Body Mass Index > 25 kg/m2. Stunting: height-for-age of -2 z scores or more below the 2006 WHO Child Growth Standards. Undernutrition: Defined as the outcome of insufficient food intake and repeated infectious diseases. It includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin for one’s height (wasted), and deficient in vitamins and minerals (micronutrient malnutrition). Underweight: weight-for-age of -2 z scores or more below the 2006 WHO Child Growth Standards. Vitamin A deficiency: defined according to a serum retinol < 0.70 μmol/L, as reported in the WHO Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005: WHO Global Database on Vitamin A Deficiency. Wasting: weight-for-height of -2 z scores or more below the 2006 WHO Child Growth Standards. 155 Table 39: Top Ten Targeted Nutrition Interventions For Djibouti, Egypt, Iraq, Morocco, and Yemen Intervention Unit Cost (US$) Approximate Total Cost Numbers of Costs as % of Return on of Scaling children or Government Investment Up (US$) people Health (%) or cost currently Expenditures28 effectiveness uncovered (US$)12, 20,21,22 who will be reached by scaling up the interventions 1. Community 16.50/child under 1400 342,853,500 21 million 2% nutrition 5/year children under programs for 5 years of age behavior change 2. Vitamin A 2.64/child aged 6- 1700 24,975,743 9.5 million <0.5% supplementation 59 months/year children 6-59 for children aged months of age 6-59 months 3. Therapeutic 2.20/child aged 6- Up to 1370 40,685,282 18.5 million <0.5% zinc 59 months/year children 6-59 supplementation months of age for children 6-59 months 4. Multi- 7.92/child aged 6- 3700 (iron) 41,063,807 5.2 million <0.5% micronutrient 23 months/year $12.20 per children 6-23 powders DALY saved months of age 5. Prophylactic 0.55/child aged 600 2,962,868 5.387million <0.5% deworming 12-59 children aged months/year 12-59 months of age 6. Iron-folic acid 4.40/pregnant or $65-115 per 12,467,884 2.8 million <0.5% supplementation lactating DALY saved pregnant and for pregnant and woman/year lactating lactating women women 7. Iron 0.20/person/year 800 9,599,000 48.0 million <0.5% fortification of people wheat flour 8. Salt iodization 0.05/person/year 3000 2,926,262 58.5 million <0.5% and iodized oil people capsules 9. 0.40/underweight 85,958,973 1.7 million 0.5% Complementary child 6-23 months children of 6- food for the of age/day 23 months of prevention and age treatment of moderate acute malnutrition 156 For Djibouti, Egypt, Iraq, Morocco, and Yemen Intervention Unit Cost (US$) Approximate Total Cost Numbers of Costs as % of Return on of Scaling children or Government Investment Up (US$) people Health (%) or cost currently Expenditures28 effectiveness uncovered (US$)12, 20,21,22 who will be reached by scaling up the interventions 10. Treatment of 200/child treated $41 per 87,674,683 438,000 0.5% severe acute DALY saved children 6-59 malnutrition months of age TOTAL 651,168,000 3.8% Source: The set of interventions, unit costs, and return on investment estimates were obtained from Scaling Up Nutrition: What will it cost?16. Methodology for the cost estimates can be found at: www.worldbank.org/nutrition/profiles 157 Table 40: Country-specific costs of scaling-up 10 key nutrition interventions from existing coverage levels to full coverage of the target population (US$ per year) Djibouti Egypt Iraq Yemen Morocco 1. Community nutrition programs for 1,782,000 155,875,500 73,425,000 61,594,500 50,176,500 behavior change 2. Vitamin A supplementation for 208,334 19,444,284 NA - targeted NA - targeted 5,323,125 children aged 6-59 months 3. Therapeutic zinc supplementation 211,464 18,497,226 8,713,100 7,309,214 5,954,278 for children 6-59 months 4. Multi-micronutrient powders for 174,630 20,222,414 9,495,086 4,878,580 6,293,096 children 6-23 months 5. Prophylactic deworming for children 40,928 NA NA 1,612,562 1,309,378 12-59 months 6. Iron-folic acid supplementation for 98,208 3,635,060 3,572,096 3,201,264 1,961,256 pregnant and lactating women 7. Iron fortification of wheat flour 169,800 4,905,400 4,219,200 183,400 121,200 8. Salt iodization 42,450 856,034 1,083,456 802,095 142,227 9. Complementary food for the 947,468 19,039,333 9,364,126 47,685,260 8,922,787 prevention and treatment of moderate acute malnutrition 10. Treatment of severe acute 1,461,024 33,631,320 17,109,360 13,821,059 21,651,920 malnutrition TOTAL 5,136,306 276,106,571 126,981,424 141,087,934 101,855,767 158 Annex 5: Statistical Data for Chapter 3 - Emerging Challenges Table 41: Age-Standardized Disability Adjusted Life Years (DALYs) per 100,000 population, by cause for MENA Countries, 2004 Communicable, maternal, perinatal and Noncommunicable nutritional conditions Diseases Injuries All DALY per DALY per DALY per causes 100,000 % total 100,000 % total 100,000 % total Non GCC MENA Algeria 17785 5307 30% 10719 60% 1759 10% Djibouti 35070 17871 51% 14329 41% 2870 8% Egypt 20261 3891 19% 14927 74% 1443 7% Iran, Islamic Republic 19432 3928 20% 12416 64% 3088 16% Iraq 50618 12103 24% 19148 38% 19367 38% Jordan 17042 2748 16% 12353 72% 1941 11% Lebanon 18881 3050 16% 13053 69% 2778 15% Libyan Arab Jamahiriya 16177 2835 18% 11562 71% 1780 11% Morocco 17780 4638 26% 11340 64% 1803 10% Syrian Arab Republic 16167 2395 15% 12315 76% 1456 9% Tunisia 15873 4216 27% 9989 63% 1668 11% Yemen 32541 11684 36% 16153 50% 4704 14% GCC Countries Bahrain 14130 1413 10% 11428 81% 1289 9% Kuwait 11659 1157 10% 9427 81% 1076 9% Oman 14459 1529 11% 11544 80% 1386 10% Qatar 11999 1351 11% 9507 79% 1141 10% Saudi Arabia 17639 2532 14% 12257 69% 2849 16% United Arab Emirates 11858 1490 13% 9247 78% 1121 9% Source: World Health Organization -Department of Measurement and Health Information, compiled from the Global Burden of Diseases statistical database available on www.who.int/evidence/bod. Notes: 1. Data for the Palestinian Territories were not available. 2. The Disability Adjusted Life Year or DALY is a health gap measure that extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of ‘healthy’ life lost by virtue of being in states of poor health or disability (1). The DALY combines in one measure the time lived with disability and the time lost due to premature mortality. One DALY can be thought of as one lost year of ‘healthy’ life and the burden of disease as a measurement of the gap between current health status and an ideal situation where everyone lives into old age free of disease and disability. 3. Cause-specific death rates were age-standardized to the WHO global standard population (see Discussion Paper 31, www.who.int/evidence). Age-standardized death rates are calculated by applying age-specific death rates for the Member State to a global standard population. Comparison of cause-specific mortality risks across countries is facilitated by the use of age-standardized death rates to adjust for differences in population age distributions. 159 Table 42: Death Rates per 100,000 population, by cause for MENA Countries, 2004 Communicable, maternal, perinatal and nutritional Noncommunicable conditions Diseases Injuries deaths deaths deaths All per per per causes 100,000 % total 100,000 % total 100,000 % total Non GCC MENA Algeria 532 160 30% 321 60% 50 9% Djibouti 1055 606 57% 375 36% 74 7% Egypt 699 121 17% 546 78% 32 5% Iran, Islamic Republic 548 80 15% 387 70% 82 15% Iraq 1349 450 33% 491 36% 408 30% Jordan 427 72 17% 307 72% 48 11% Lebanon 750 77 10% 589 78% 85 11% Libyan Arab Jamahiriya 451 73 16% 330 73% 49 11% Morocco 552 112 20% 398 72% 42 8% Syrian Arab Republic 388 56 14% 296 76% 36 9% Tunisia 590 160 27% 382 65% 48 8% Yemen 901 425 47% 382 42% 94 10% GCC Countries Bahrain 355 32 9% 289 81% 34 10% Kuwait 176 18 10% 130 74% 27 16% Oman 310 25 8% 250 81% 35 11% Qatar 189 23 12% 135 72% 30 16% Saudi Arabia 425 69 16% 285 67% 71 17% United Arab Emirates 156 25 16% 100 64% 31 20% Source: World Health Organization -Department of Measurement and Health Information, compiled from the Global Burden of Diseases statistical database available on www.who.int/evidence/bod. Notes: 1. Data for the Palestinian Territories were not available. 160 Table 43: Access to basic health services in selected MENA countries Immunization, Births Population Population Immunization, measles in attended by with access with access DPT in 2007 2007 (% of Contraceptive skilled to local to local (% of children children ages prevalence health staff health health ages 12-23 12-23 (% of women (% of total services services months) months) ages 15-49) Year births) Year (urban) (rural) Year Algeria 95 92 61.4 2006 95.2 2006 .. .. Djibouti 88 74 17.8 2006 92.9 2006 100 n/a 2002 Egypt 98 97 59.2 2005 74.2 2005 100 100 2008 Iran 99 97 78.9 2005 97.3 2005 100 95 2008 Iraq .. .. 49.8 2007 88 2006 98 87 2008 Jordan 98 95 57.1 2007 99 2007 100 96 2001 Lebanon 74 53 58 2005 98 2004 99 97 2000 Libya 98 98 53.7 2004 100 2006 100 100 2008 Morocco 95 95 63 2004 61 2004 66 77 2008 Palestinian Terr. .. .. 50.2 2006 98.9 2006 100 100 2008 Syria 99 98 58.3 2006 93 2006 100 90 2008 Tunisia 98 98 60 2006 95 2006 100 100 2008 Yemen 87 74 27.7 2006 35.7 2006 80 25 2008 GCC Bahrain 97 99 54 2006 99 2005 100 100 2003 Kuwait 99 99 50 2003 98 2006 100 100 2003 Oman 99 97 32 2000 98.1 2006 100 95 2008 Qatar 94 92 .. .. 100 2006 100 100 2002 Saudi Arabia 96 96 32 2003 96 2004 100 95 1996 United Arab Emirates 92 92 .. .. 100 2006 100 100 2008 Sources: The World Bank, World Development Indicators, 2009; and WHO EMRO Health System Observatory Data Base, 2010. 161 Annex 6: Statistical Tables for Road Traffic Injuries Chapter Table 44: Road Safety Requirements and Compliance Rates, MENA Countries 2010 Maximum Urban Speed Limit Drink-driving law Motorcycle helmet Seatbelt law % road traffic Com- Legis- death Legis- Com- Legis- pliance Enforce lative due to Enforce lative pliance Enforce- lative Enforce rate Country Km/h -ment/a Status alcohol -ment/a Status rate ment/a Status -ment/a Algeria Bahrain 50 4 Yes 8% 4 Yes n/a 5 Yes 22% 4 Djibouti Egypt 60 6 Yes n/a 4 Yes 70% 6 Yes 70% 7 Iran, I.R./b 50 6 Yes n/a 1 Yes 13- 6 Yes 75- 8 15% 80% Iraq 100 5 Yes n/a 5 No - - Yes n/a 8 Jordan 50-80 6 Yes n/a 3 Yes n/a 4 Yes 65% 5 Kuwait 45 6 Yes n/a 9 Yes n/a 3 Yes n/a 3 Lebanon 100 4 Yes n/a 1 Yes n/a 2 Yes 15% 4 Libya, Arab 50 3 Yes 2% 5 Yes n/a 7 Yes 5% 4 Jamahariyya Morocco 60 5 No 3% - Yes 67% 4 Yes 75% 8 Oman 120 6 Yes n/a 4 Yes n/a 7 Yes 95% 9 Palestinian 50 3 Yes n/a 1 Yes n/a 3 Yes n/a 3 Territories Qatar 100 7 Yes n/a 6 Yes 90% 5 Yes 50% 7 Saudi 80 5 Yes n/a 7 Yes n/a 2 Yes n/a 5 Arabia Syria 45-60 8 Yes n/a 8 Yes n/a 4 Yes 81% 9 Tunisia 50 5 Yes 1% 3 Yes n/a 5 Yes n/a 2 United Arab 60 7 Yes n/a 8 Yes n/a 8 Yes 61% 7 Emirates Yemen n/a 3 Yes n/a n/a No - - No - - a. Enforcement score represents consensus based on professional opinion of respondents, on a scale of 0 to 10 where 0 is not effective and 10 is highly effective. b. Alcohol consumption is prohibited by law. c. km/h = Kilometers per hour. 162 Table 45: Institutional Framework for Road Safety, MENA Countries in 2007 Funded Formal in National Measur- Road National Road Safety able Safety Country Lead Agency Budget Strategy Targets Funded Audits Algeria Bahrain General Directorate of Traffic Yes n/a n/a n/a Yes Djibouti Egypt National Council for Road Yes Yes No No Yes Safety Iran, I.R. Headquarter for Yes multiple n/a N/a Yes Transportation and Fuel Management Iraq Supreme Council Road Safety No No n/a n/a No (subnational) Jordan Road Safety Council No Yes n/a n/a No Kuwait No n/a No n/a n/a No Lebanon No n/a Yes n/a n/a Yes Libya, Arab No n/a No n/a n/a No Jamahariyya Morocco Interministerial Committee for No Yes Yes Yes No Road safety Oman Yes (name n/a) Yes No n/a n/a Yes Palestinian No n/a No n/a n/a No Territory Qatar No No No n/a n/a Yes Saudi Arabia High Council for Traffic Yes Multiple n/a n/a Yes Syria National Committee for Road No Multiple n/a n/a Yes Safety Tunisia National Observatory for Yes Yes Yes Yes No Information, Training, Documentation and Study on Road Safety United Arab Ministry of Interior and Yes Yes Yes Yes Yes Emirates National Transport Authority Yemen National Committee for Road No Multiple n/a n/a No Safety Source: National sources as reported in (World Health Organization, 2009b). 163 Annex 7: Statistical Tables for NCD Chapter Table 46: Prevalence of Obesity (% of population, Body Mass Index ≥30kg/cm2) MENA countries and selected comparator countries, 2002 Non-GCC MENA Males Females GCC countries Males Females Countries Jordan 19.6 40.2 Bahrain 21.2 33.5 Egypt 19.6 39.3 Kuwait 29.6 49.2 Tunisia 7.7 28.8 United Arab Emirates 24.5 37.9 Iran, Islamic Republic of 9.4 25.0 Saudi Arabia 22.3 32.8 Lebanon 14.9 23.9 Qatar 16.6 27.9 Libyan Arab Jamahiriya 10.7 21.1 Oman 7.7 13.5 Syrian Arab Republic 10.5 20.8 Morocco 3.7 19.0 Algeria 4.5 11.9 Djibouti 1.2 5.0 Yemen 2.0 4.4 Males Females Comparator Countries Mexico 20.3 31.6 Costa Rica 10.6 22.7 Malaysia 1.6 6.8 Indonesia 0.2 2 Turkey 10.8 32.1 Japan 1.5 1.5 Source: Infobase WHO Accessed May 2010. 164 Table 47: Taxes and Retail Price for a Pack of 20 Cigarettes in MENA, 2008 Adult Average daily price per Specific excise tax per Total * smoking pack pack Ad valorem excise tax taxation prevalence Countries US$ (%) US$ (%) US$ (%) Percent?? Algeria 0.98 53 0.52 0 0.00 68 27 Djibouti 0.68 0 0 44 0.30 44 … Egypt 0.49 59 0.29 0 0.00 59 26 Iran 1.32 0 0.00 5 0.07 19 23 Iraq 0.63 0 0.00 9 0.06 23 19 Jordan 1.97 23 0.45 32 0.63 69 61 Lebanon 1.33 0 0.00 33 0.44 44 27 Libya 0.8 0 0 2 0.02 2 .. Morocco 2.16 1 0.02 50 1.08 66 28 Palestinian Terr. 2.1 .. .. .. .. … .. Syria 0.62 3 0.02 11 0.07 30 41 Tunisia 1.3 2 0.03 47 0.61 65 56 Yemen 0.75 0 0 47 0.35 47 21 GCC Countries Bahrain 1.6 0 0 0 0.00 33 10 Kuwait 1.7 0 0 0 0.00 34 33 Oman 1.56 0 0 0 0 33 8 Qatar 1.65 0 0 0 0 33 .. Saudi Arabia 1.6 0 0 0 0 33 11 UAE 1.77 0 0 0 0 31 14 High Income 4.99 .. 2.66 .. 0.47 63 .. Middle income 2.06 .. 0.73 .. 0.28 49 .. Low income 1.06 .. 0.27 .. 0.14 39 .. Global 2.54 .. 0.95 .. 1.26 50 .. Source: Using data from (World Health Organization, 2009c) Note: * includes VAT and taxes other than exise tax; all data points are in 2008. 165 Table 48: Population Goals for Nutrients and Features of Lifestyle Consistent with Major Public Health Problems in Europe Source: European Commission, 2000 166 Table 49: Incremental Cost-effectiveness of Selected Population-based and Clinic-based Interventions in the MENA Region Range in cost per Risk factor QALY averted Target type Intervention (high to low effect) Population- Tobacco 33% price increase $6 - $89 based Nicotine replacement therapy $47 - $750 Non-price interventions $115 - $1,432 Diet Saturated fat reduction $4,012 Trans fats reduction by substitution $25 - $2,259 Salt reduction by legislation and $3,056 public education Injury Publicized traffic enforcement of $1,365 - $2,166 seatbelts, child restraints, and breath test Speed bumps at 10% of most lethal $150 - $238 junctions Clinic-based Complications Heart attacks Aspirin $17 Aspirin +BP med $20 Asprin+ BP med+streptokinase $715 Aspirin+BP med +streptokinase $15,893 +tissue plasminogen activator Diabetes Blood Pressure control Cost saving Foot care Cost saving Improved blood glucose control Cost saving (HbA1c < 9.0) Source: (Jamison & Bremen, 2006). Note: These models are based on the best available data but their usefulness may vary widely across countries and regions. 167 Table 50: Tobacco Consumption Information for MENA and comparison countries, 2006 Age adjusted Smoking among prevalence daily Youth smokers per 100 age 13-15 Country males females males females High Income Bahrain 13.2 1.7 28.0 11.7 Kuwait * * 28.0 14.3 Oman 11.0 0.3 24.1 7.6 Qatar * * 21.1 12.7 Saudi Arabia 13.2 2.4 * * UAE 13.9 1.2 25.2 13.2 Middle Income Algeria Djibouti * * 17.2 10.7 Egypt 27.1 1.2 16.0 7.6 Iran, IR 23.1 4.0 17.6 8.9 Iraq 10.0 1.6 29.0 13.1 Jordan 62.7 9.8 31.6 24.0 Lebanon 27.5 7.0 65.8 54.1 Libya * * 16.8 8.1 Morocco 27.9 0.2 12.5 8.2 Palestinian Territories * * 37.8 17.4 Syria 42.0 22.9 15.0 Tunisia 49.2 1.9 24.9 6.0 Low income Yemen * * 19.7 13.7 Benchmark Countries Mexico 21 6 21 6 Costa Rica 9.9 2.4 25 6 Malaysia 42 2 42 2 Turkey 45 15 45 15 Source: (World Health Organization, 2009c) 168 Annex 8: Tables and Data for Chapter on Equity and Out-of-Pocket Payments Table 51 Out of Pocket and Catastrophic Payments on Health – Data Sources and Descriptions Country Year Survey Sample size Survey Type Recall Poverty Line (No. of period households) Yemen 2005/6 Household Budget 13,136 National 1 month World Bank Survey poverty line of $1.08/day Libya 2002/3 Economic and Social 11,111 National 1 month National poverty Survey line of one-third mean per capita income Lebanon 2004/5 Multi-Purpose 13,000 National 1 month National poverty Survey of line of $4.4/day Households Palestinian 1998, Palestine 1,440 National 1 month World Bank Territories 2004, Consumption and poverty line of 2005, Expenditure Survey $2.15/day 2006, 2007 (PECS) Iran 1996, Household 22,000 – National 1 month World Bank 2001, 2006 Expenditure and 31,000 poverty line of Income Survey $2.15/day Egypt 2006/7 User-Fee Exemption 2,954 Four 1 month National poverty Program, Baseline governorates line of LE and Follow-up (Alexandria, 118.59/day Survey; included for Manoufieh, purposes of impact Qana, Suez); evaluation example Regionally representative Tunisia 2005 National Health 6,538 National 1 month World Bank Survey (L’enquête poverty line of nationale de santé) $2.15/day Sources: Yemen: Central Statistical Organization; Libya: National Corporation for Information and Documentation; Lebanon: Ministry of Social Affairs and Central Administration for Statistics;Palestinian Central Bureau of Statistics; Iran: Statistical Center of Iran; Egypt: Ministry of Health; Tunisia: Ministry of Public Health. 169 Annex 9: Statistical Annex on Health Financing in MENA Region Table 52: Total Health Expenditures as a Percent of GDP, MENA Countries and Global averages, 1995 – 2008 Annualized Countries/ Income Groups 1995 2008 % change % change Gulf Cooperation Council Countries Bahrain 4.6 3.6 -22% -0.8% Kuwait 3.9 2.0 -49% -2.2% Oman 3.6 2.4 -34% -1.4% Qatar 3.7 3.3 -10% -0.3% Saudi Arabia 2.3 3.3 47% 1.3% United Arab Emirates 4.0 2.4 -40% -1.7% GCC/ High Income Mean 3.7 2.8 -23% -0.9% High Income Mean (global) 6.8 7.5 11% 0.3% Middle Income Countries Algeria 4.2 4.5 8% 0.2% Egypt 3.9 4.8 22% 0.7% Iran 4.7 6.3 35% 1.0% Jordan 7.7 9.1 18% 0.6% Libya 3.7 2.8 -23% -0.9% Morocco 3.9 5.3 37% 1.1% Syria 5.5 3.2 -42% -1.8% Tunisia 6.1 6.0 -3% -0.1% Lebanon 10.7 8.8 -18% -0.7% Djibouti 4.0 8.5 112% 2.5% Iraq/ 1996 figure 1.0 2.7 170% 3.4% Palestinian Territories 8.3 n/a n/a n/a MENA Middle Income Mean 5.7 5.6 -1% -0.04% Middle Income Mean (global) 5.6 6.2 11% 0.3% Low Income Countries Yemen 4.5 3.7 -18% -0.7% Low Income Mean (global) 4.0 5.7 43% 1.2% Source: Calculated from WHO-WHOSIS National Health Accounts; accessed May 2010. 170 Table 53: Total Per Capita Health Expenditures (in constant 1995 US$) Total Annualized Percent 1995 2008 Percent Change Change 1995-2008 Gulf Cooperation Council Countries Bahrain 556 921 66% 1.7% Kuwait 740 927 25% 0.8% Oman 279 422 51% 1.4% Qatar 683 2,704 296% 4.7% Saudi Arabia 214 572 168% 3.3% United Arab Emirates 858 1,429 66% 1.7% GCC/ High Income Mean 555 1,162 109% 2.5% Global High Income Mean 1,697 3,066 81% 2.0% Middle Income Countries Algeria 75 205 175% 3.4% Egypt 44 111 151% 3.1% Iran 96 294 208% 3.8% Jordan 145 273 88% 2.1% Libya 232 383 65% 1.7% Morocco 58 133 131% 2.8% Syria 60 76 27% 0.8% Tunisia 149 213 43% 1.2% Lebanon 431 551 28% 0.8% Djibouti 39 81 110% 2.5% Iraq n/a 88 n/a n/a Palestinian Territories 181 n/a n/a n/a Middle Income Mean 137 219 60% 1.6% Global Middle Income mean 145 273 88% 2.1% Low Income Countries Yemen 46 46 -1% -0.04% Global Low Income Mean 19 31 66% 1.7% Source: Calculated from WHO-WHOSIS National Health Accounts; accessed May 2010. 171 Table 54: Public Spending on Health as Percentage of Total Government Spending in MENA with Global Averages, 1995-2008 % Annualized Countries/ Income Groups 1995 2008 change % change Gulf Cooperation Council Countries Bahrain 11.3 9.8 -13% -0.5% Kuwait 6.3 6.3 0% 0.0% Oman 6.9 4.7 -32% -1.3% Qatar 5.0 9.7 94% 2.2% Saudi Arabia 4.7 8.8 85% 2.1% United Arab Emirates 8.1 8.9 10% 0.3% GCC/ High Income Mean 7.0 8.0 14% 0.4% High Income Mean (global) 11.6 14.1 22% 0.7% Middle Income Countries Algeria 10.0 10.7 6% 0.2% Egypt 5.3 7.1 34% 1.0% Iran 9.3 11.4 23% 0.7% Jordan 14.3 11.4 -21% -0.8% Libya 6.1 5.4 -12% -0.4% Morocco 3.8 6.2 63% 1.7% Syria 7.7 6.0 -22% -0.8% Tunisia 8.2 8.9 9% 0.3% Lebanon 9.8 12.4 26% 0.8% Djibouti 6.2 14.2 127% 2.8% Iraq/ 1996 figure 1.9 3.1 58% 1.7% Palestinian Territories MENA Middle Income Mean 8.1 8.8 9% 0.3% Middle Income Mean (global) 9.8 10.6 8% 0.3% Low Income Countries Yemen 6.9 4.5 -35% -1.4% Low Income Mean (global) 7.9 9.6 22% 0.7% Source: Calculated from WHO-WHOSIS National Health Accounts; accessed May 2010. 172 Table 55: Out of Pocket Spending as % of Total Health Expenditure in MENA Region with Global Averages, 1995-2008 Annualized Countries/ Income Groups 1995 2008 % change % change Gulf Cooperation Council Countries Bahrain 21.7 19.7 -9% -0.3% Kuwait 16.3 21.3 30% 0.9% Oman 10.2 17.0 67% 1.7% Qatar 35.0 26.5 -24% -0.9% Saudi Arabia 15.3 6.3 -59% -2.9% United Arab Emirates 56.1 45.5 -19% -0.7% GCC/ High Income Mean 25.8 22.7 -12% -0.4% High Income Mean (global) 22.1 20.8 -6% -0.2% Middle Income Countries Algeria 23.9 15.3 -36% -1.5% Egypt 48.0 58.7 22% 0.7% Iran 46.3 51.7 12% 0.4% Jordan 24.4 33.4 37% 1.1% Libya 48.1 24.1 -50% -2.3% Morocco 52.7 56.1 6% 0.2% Syria 60.3 54.9 -9% -0.3% Tunisia 37.9 42.5 12% 0.4% Lebanon 55.3 40.0 -28% -1.1% Djibouti 39.3 23.6 -40% -1.7% Iraq/ 1996 59.0 18.8 -68% -4.1% Palestinian Territories/ 1996 46.1 n/a n/a n/a MENA Middle Income Mean 43.6 40.0 -8% -0.3% Middle Income Mean (global) 35.4 32.2 -9% -0.3% Low Income Countries Yemen 65.5 58.0 -11% -0.4% Low Income Mean (global) 50.0 45.8 -9% -0.3% Source: Calculated from WHO-WHOSIS National Health Accounts; accessed May 2010. 173 Table 56: Private Insurance as Percentage of Total Private Health Expenditure in MENA with Global Average, 1995-2008 Annualized 1995 2008 % change % change Gulf Countries Bahrain 23.39 14.88 -36% -1.5% Kuwait 6.20 8.43 36% 1.0% Oman 23.12 24.01 4% 0.1% Qatar 0.00 0.00 0 0 Saudi Arabia 13.63 36.66 169% 3.4% United Arab Emirates 19.66 22.23 13% 0.4% GCC/ High Income Mean 14.33 17.70 24% 0.7% High Income Mean (global) 17.59 17.96 2% 0.1% Middle Income Countries Algeria 2.91 5.13 76% 1.9% Egypt 1.02 0.22 -79% -5.0% Iran 1.96 3.80 94% 2.2% Jordan 4.73 6.90 46% 1.3% Libya 0.00 0.00 0% 0.0% Morocco 22.19 13.69 -38% -1.6% Syria 0.00 0.00 0% 0.0% Tunisia 19.94 16.58 -17% -0.6% Lebanon 20.36 17.30 -15% -0.5% Djibouti 1.70 1.37 -20% -0.7% Iraq n/a 0.00 n/a n/a Palestinian Territories n/a n/a n/a n/a MENA Middle Income Mean 7.48 6.50 -13% -0.5% Middle Income Mean (global) 8.86 8.24 -7% -0.2% Low Income Countries Yemen 2.21 1.60 -27% -1.1% Low Income Mean (global) 2.11 3.04 44% 1.2% Source: Calculated from WHO-WHOSIS National Health Accounts; 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