J~~~~~~~ t; -~~~~~~i 4-" 16~~~~~~~~~~~~~~~~~~~~~I LC)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~C Public Health in Middle East and North Africa: A Situation Analysis June 10, 2002 "Health Care is vital to all of us some of the time, but Public Health is vital to all of us all of the time. " By C. Everett Koop This paper was produced by Juliana Yartey, MPH, DrPH of the Johns Hopkins School of Public Health tinder the direction of Maryse Pierre-Louis, Lead Public Health Specialist, Middle East and North Africa Region Peer reviewers are Mariam Claeson, Principal Public Health Specialist, World Bank, and Sahlii Habayeb, Lead Public Health Specialist, South Asia Region, World Bank The MNSHD Health Team of the Middle East and North Africa Region provided significant input and support to the elaboration of this paper Purpose of Document The purpose of this document is to provide an overview of the public health situation in the Middle East and North Africa (MENA) region, which aims to stimulate dialogue with officials in MENA countries on the issues identified, and provide a knowledge base for the r egion's public health strategy. The review focuses on the health situation in the region, demographic and epidemiological trends, activities already undertaken by governments and other agencies to improve the health of the population - including World Bank assistance, identification of gaps in current efforts, and the implications for a future regional public health strategy. The document is not a strategic document; complimentary reviews will be prepared to this end. Rather, it presents an overview of the public health situation and recommendations for strategic directions in assuring optimum health for all populations in the region within the context of limited resources, changing lifestyle and health patterns resulting from the ongoing demographic and health transitions and globalization. The Process The review was based on the MENA regional Health, Nutrition and Population (HNP) Sector Strategy Paper, and other key documents produced for the region either by the World Bank or other donors The review was also based on discussions with various health experts (World Bank health team members and task team leaders) and health experts from other units of the World Bank. List of Countries Considered Countries in the MENA region of the World Bank include: Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates (UAE), West Bank and -Gaza, and Yemen. The countries are grouped by economic strength as follows: co untries of the oil exporting Gulf Cooperation Council (GCC) comprising of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and UAE are categorized as upper middle-or high-income countries, based on their GDP per capita. Algeria, Egypt, Iran, Iraq, Jordan, Lebanon, Morocco, Syria, Tunisia and the West Bank and Gaza are considered to be lower middle-income countries. Yemen and Djibouti, the least developed countries in the region, are the considered as low-income countries. Acknowledgements Sincere thanks is extended to all resource persons who contributed to the preparation of this document in various ways, especially the MNSHD health team for their input, guidance and advice. Special thanks go to George Schieber, Health and Social Protection Manager, for his valuable input and support for the preparation of this document, and to Emma Paulette Etori and Hennette Folquet, Language Team Assistants, for their technical assistance and support in the preparation of this document. Page i TABLE OF CONTENTS Executive Sunim ay .......... ........ .. ...... ...... .....v I Introduction ..... ......... . .. .......... .. ............. .. ... 2 Regional Context ......... ....... ........ . . .... .. 4 2.1 Economic, Political and Social ...... .. ..................................................... 4 2.1.1. Urbanization . . ........... . .. ............... ......... 5 2.1.2. Health and Social Services . . ....................................5..... ........... ... .5 2.1.3. Water and Sanitation ............ . ......... .6 .......... .................................6 2.1.4. Education ................. . ....................... ......... ......... 6 2.2. Demographic Profile .....7 3 Health Systems in MENA ............ ..... 9 3.1. Performance of MENA Health Systems ............ .......................... ............. . . 9 3.2. Health Services Infrastructure, Resources and Capacity ....1 0 3.3. Health Expenditures and Financing . . . ..................... 10 3.3.1. Public Health Financing . . . 3.3.2. National Health Accounts (NHA) . .12 4 Public Health Situation.. .......... ... .... 4 4.1. Nutrition ...................................................................................................... l5 4.2. Reproductive Health . . ......................... 16 4.3. Women's Status . . . ........................ 18 4.4. Communicable Diseases ................... ............... . .......... ........... ............ 21 4.4.1 Vaccine Preventable Diseases . . . 21 4.4.2 Acute Respiratory Infections . . ........ .................. 21 4 4.3 HIV/AIDS ............... ...... .. 22 4.4.4 Tuberculosis ..................... ................................................. 23 4.4.5 Malaria ......... ............ ... 24 4.5. Non-Communicable Diseases . . . ...... .......... ..26 4.5.1. Cardiovascular Diseases ....................... 27 4.5.2. Cancer ............................2.................... ....... .. .. 27 4.5.3. Tobacco-related Diseases . . .......................... 29 4.5.4. Other Chronic Diseases . . .......................... 32 4.5.5. Nutrition and Physical Activity . . ........................ 32 4.5.6. Alcohol Use ... ......................... 32 4.6. Injuries ...... ............................. ............................3......................... 33 4.7. Demographic and Epidemiological Transitions ....................................... 34 5. Public Health Activities .... . ...... .. ....... ....... ....... ....... 38 5.1. Government Activities . . . . 38 5.2. Activities of Other Organizations . . . . 38 5.3. Bank Assistance . . . . 39 5 3.1. Current Agenda . . ........................... 39 5.3.2. Gender Initiatives .. ................. ...... ..... .... 40 5.3.3. National Health Accounts Initiative . . 40 5.3.4. Other Bank Activities . . ... ................. 40 5.3.5. Role of the World Bank in Future Public Health Strategies ....... 41 6. Conclusions and Recommendations . . . ................................... ....... ... 42 References ... ..... . .76 Page ii APPENDICES I Economic Indicators 2 Health Services Infrastructure, Resources and Capacity 3 Health Expenditure Patterns 4 Spectium of Health Activities 5. Immunization Profile 6 HIV/AIDS in Middle East and North Africa 7 a) Tuberculosis Rates-Eastern Mediterranean Region b) Tuberculosis Cases (Regional Profile-EMR (1998) 8 Smoking Prevalence and Tobacco Related Mortality from Cancer 9. Prevalence of Smoking among Adults aged 15 and over, by Region 10 Changes in Disease Burden 11 Burden of Disease Trends (1990-2010) 12 Deaths by Cause in the Middle Eastern Crescent 13 Leading Causes of Deaths, Both Sexes, Global, 1998 14. Leading Causes of Disease, Both Sexes, Global, 1998 15 Leading Causes of Disease, Eastern Mediterranean Region - High-income Countries, Both Sexes, Global, 1998 16. Leading Causes of Burden of Disease, Eastern Mediterranean Region - High-income Countries, Both Sexes, Global, 1998 17 Leading Causes of Disease, Eastern Mediterranean Region - Low- and Middle-income Countries, Both Sexes, Global, 1998 18. Leading Causes of Burden of Disease, Eastern Mediterranean Region - Low- and Middle-income Countries, Both Sexes, Global, 1998 19 Life Expectancy at Birth, 1999 20. Infant Mortality Rates, 1999 21 Global Trends in Infant Mortality 22 Global Trends in Infant Mortality, 1999 23 Population Growth Rates, 1999 24 Child Malnutrition-Underweighit ANNEXES Annex A Sources of Information Annex B. Current Ongoing Health Projects in MENA Annex D Bank Lending Page iii TABLES, FIGURES AND BOXES TABLE I ACCESS TO HEALTI H AND SOCIAL SERVICES 7 TABLE 2 DEMOGRAPHIC PROFILE . TABLE 3 HEAITH STATUS INDICATORS 14. .. TABLE- 4 NUTRITIONAL STATUS INDICATORS ..16 TABLE 5 REPRODUCTIVE HEALTH INDICATORS (MENA) 18 TABLE 6 LEADING CAUSES OF MORTALIT1 Y AND DALYS AND THEIR RANKS IN WHO REGIONS 26 FIGURE IA HEALTH EXPENDITURES AS PERCENT OF GDP GLOBAL TRENDS, MID 1990S 12 FIGURE IB H EALTH EXPENDITURESASPERCENTOFGDPGLOBALTRENDS, MID I990S 13 FIGURE 2 FERTILITY RATI ES IN MENA 19 FIGURE 3A MATERNAL DEATI IS IN MENA, 1999 19 FIGURE 3B GLOBAL TRENDS IN MATI ERNAL MORT ALITY, 1999 20 FIGURE 3c GLOBAL TRENDS IN MATERNAL MORTALITY, 1999 20 FIGURE 4 SMOKING PREVALENCE AND CANCER (LUNG, TRACHEA AND BRONCHUS) 31 FIGURE 5 THE DEMOGRAPHIC TRANSITION 36 FIGURr 6 CRUDE BIRTH AND DEATII RATES OF COUNTRIES IN MENA 36 FIGURE 7 CHANGING DISEASE BURDEN - MENA .37 FIGURE 8 TRENDS IN DEATI HS BY CAUSE IN THE MIDDLE EASTERN CRFSCENT 37 Box I ESSENTIAL PUBLIC HEALTH SERVICES .3 Box 2 PUBLIC HEALIH FUNCTIONS AND EXAMP3LES OF ACTIVITIES 3 Box 3 COMMUNICABLE DISEASES. 25 Box 4 NON-COMMUNICABLI DISEASES 28 Box 5 INJURIES 34 Page i v ACRONYMS AND ABBREVIATIONS AIDS Acquired immunodeficiency syndrome ALRI Acute lower respiratory infections BMI Body mass index CAS Country assistance strategy CDC Centers for Disease Control and Prevention CVD Cardiovascular disease DALYs Disability adjusted life years DOTS Directly Observed Therapy Short course (World Health Organization) EMR Eastern Mediterranean region EMRO World Health Organization's Regional Office for the Eastern Mediterranean EOC Essential Obstetric Care EPI Expanded program on immunization FGC Female genital cutting GCC Gulf Cooperation Council GDP Gross domestic product GNP Gross national product HIV Human immunodeficiency virus HNP Health, nutntion, and population 1BRD International Bank for Reconstruction and Developm ent ICPD International Conference on Population and Development IDA International Development Association IDD Iodine deficiency disorders IEC Information, Education and Communication IMR Infant mortality rate LJNAIDS Joint United Nations Program on HIV/AID S MAP Multi-country Aids Program (World Bank) MENA Middle East and North Africa MCH Maternal and child health MMR Maternal mortality ratio MOH Ministry of Health MNSHD Middle East and North Africa Region, Human Development Group (World Bank) NGO Non-governmental organization OECD Organization for Economic Cooperation and Development PHC Primary health care RBM Roll Back Malaria STI (STD) Sexually transmitted infections (Sexually transmitted diseases) TFR Total fertility rate U5MR Under-five child mortality rate UAE United Arab Emirates UN United Nations UNDP United Nations Development Program UNFPA United Nations Population Fund UNICEF United Nations Children's Fund UNRWA United Nations Relief and Work Agency for Palestine Refugees in the Near East USAID United States Agency for International Development WBG West Bank and Gaza WFP World Food Program WHO World Health Organization Page v Executive Summary Significant improvements in health status, morbidity and mortality have been achieved in the Middle East and North Africa (MENA) region over the last twenty years, largely through improvements in technology, health services delivery, public health programs and socioeconomic development. Infant mortality rate has declined from 54 deaths per 1,000 live births in 19 95, to a current estimate of 45 deaths per 1,000 live births, compared to a rate of 135 deaths per 1,000 live births in 1970, and life expectancy at birth has increased from about 52 years in 1970 to a currenit regional average of 68 years. Despite these significant accomplishments, immense challenges stand in the way of achieving optimal health for all. In most countries of the region, Infectious diseases remain high while non-communicable diseases, emerging and reemerging infectious diseases and injuries increase with rapid urbanization and changing lifestyles. Demographic and Epidemiological Transitions Presently, countries in the region are at substantially different stages of the demographic transition Yemen and Djibouti, both low-income countries, are in the early (second) stage of the demographic transition with relatively high rates of fertility (>30 births per 1,000 population) and mortality (>10 deaths per 1,000 population), and demographic profiles comparable to the lcast developed countries of the world. Iraq, unlike Yemen or Djibouti, is relatively wealthier, but is also at the early stage of the transition with high fertility and mortality levels due to deteriorating health and socioeconomic conditions, as a result of economic sanctions since 1991 The middle-incomc countries of Algeria, Egypt, Iran, Lebanon, Morocco and Tunisia have declining fertility (17 to 30 births per 1,000) and mortality rates (5 to 10 deaths per 1,000), and appear to be in the third stage of the transition (mid-transition). Typically, most middle-income countries tend to be at the third stage of the demographic transition. United Arab Emirates (UAE) and Kuwait, both upper milddle - income countries, have low fertility and mortality rates and seem to have began the fo urth stage of the transition as most developed countries. Interestingly, other upper middle -income countries such as Saudi Arabia and Oman appear to be at the third stage of the transition with very high birth rates (>28 births per 1,000) and low mortality rates (<5 deaths per 1,000) that are comparable to the newly industrialized countries of East Asia, i.e. Indonesia and Malaysia. Over the next two decades, health pattems in the MENA region will be profoundly influenced by continued declines in fertility and mortality as the countries go through the demographic transition A 50 percent decline in fertility with modest gains in life expectancy is projected for the region by World Bank estimates. The overall effect of the declines in fertility and morta lity is a dramatic shift in the age structure and causes of morbidity and mortality. Several lower middle -income countries in the region will have 5 percent or more of their populations over age 65, and the challenges of an aging population, which include a substantial nse in non-communicable diseases and injuries, and demand for long-term care will become prominent. By the year 2020, it is estimated that chronic diseases will account for 60 percent of disease burden and 72 percent of deaths in the MENA region, as compared with 45 percent of disease burden and 56 percent of deaths today. The proportion of disease burden due to communicable diseases is expected to decline from 40 percent in 2000 to 20 percent by the year 2020 (figure 7). The rapid urbanization, industrialization and mechanization of agriculture by countries in the region, most of which lack the infrastructure to institute controls and reduce risks, is likely to result in unprecedented high levels of accidents and injuries. Hence, the burden of injuries is expected to increase from 15.4 percent in 2000 to 20 percent in 2020. Already, according to WHO, injuries were the leading cause of death among the economically productive age group (15 to 44 years) of both high - and low-income countries of the region m 1998. These trends have important implications for public health policy and Page vi programs, and the organization and delivery of health services in the region. The future challenge for governments will be to develop and implement appropriate health promotion and disease prevention (public health) programs to reduce the incidence of expensive-to-treat non- communicable diseases and injuries. Most of the low- and middle-income countries in the region are presently undergoing a period of "protracted polarized" epidemiological transition. This is characterized by an overall decline in mortality but with persistent high incidence of infectious diseases among certain groups, usually the rural poor, and a concurrent rise in the proportion of disease burden attributable to non-communicable diseases In all countries of the region, while non-communicable diseases are increasingly becoming the major cause of death, infectious diseases continue to be responsible for a significant number of deaths at all ages. For example, in 1998, although ischemic heart disease was the leading cause of death in the low- and middle-income countnes of the region, infectious diseases (diarrhea and ALRI) were responsible for a higher number of deaths for all ages combined. This situation clearly indicates initiation of an epidemiological polarization in some middle -income countries of the region. One consequence of the epidemiological polarization is its widening effect on the disparities between the urban and rural populations, and between the wealthy and the poor. The treatment of non-communicable diseases is relatively costly and technology intensive. Consequently, an increasing share of resources is channeled toward the treatment of these cases, which usually benefits the urban population and leaves a smaller share of resources for the rural poor Fmding a balance between the competing demands on resources presents a major challenge for these middle-income countries. Despite overall improvements in living standards and health services in the region, wide disparities in health status persist. For example, infant mortality rates vary from 8 deaths per 1,000 live births in the UAE to over 100 in Djibouti and Iraq, and under five mortality ranges from 10 per 1,000 live births in the UAE to 125 in Iraq. The proportion of children under age 5 who are malnourished varies from 2 percent in Kuwait to 46 percent in Yemen. These disparities are influenced by differences in the levels of socioeconomic development and acces s to health and social services Some low- and middle-income countres in the region such as Djibouti, Iraq, Morocco, parts of Egypt and Yemen continue to suffer high mortality rates from infectious diseases such as diarrhea and respiratory infections, as well as matemal and pennatal conditions Although most countres in the region have attained high rates of immunization, coverage in Djibouti, Yemen and Iraq is low. The situation in Djibouti is particularly troubling with less than 40 percent coverag e for all immunizations. Compared to other middle-income countries, the MENA region has high fertility rates, which are more characteristic of a low-income region. Although fertility has declined substantially over the past two decades, total fertility rates are high, ranging from 2.2 in Tunisia to 6 3 in Yemen, with a regional average of 3.5 births per woman. Even middle -income countries such as Syria, Oman and Jordan have fertility rates ranging between 4.0 and 4.6 births per woman, and Saudi Arabia, which is one of the richest countries in the region, has one of the highest fertility rates (5.7 births per woman). Adolescent fertility rates are also very high. Saudi Arabia has the highest adolescent fertility rate (112 births per 1,000 adolescents), followed by Yemen (103) and the West Bank and Gaza (98 births per 1,000 adolescents). Although the impact of rapid population growth on health and socioeconomic development is controversial, in low -income countries, rapid population growth places a tremendous burden on national resources and may negatively impact socioeconomic development. Despite high fertility and population growth, less than half of the countries in the region have explicit population policies to lower fertility. Modem contraceptive use is low, and access to family planning services is limited. Although matemal mortality ratios (MMR) have declined significantly in most of the higher income countries (e.g., Kuwait and UAE), very high rates (>200 deaths per 100,000 live births) persist in Djibouti, Yemen, rural parts of Morocco and Page vii Egypt. Less than 50 percent of deliveries in Egypt, Morocco and Yemncl are assisted by skilled personnel, and only 19 percent of pregnant women in Yemenl receive tetanus vaccInation - an indication of poor access to and quality of maternal health services in these countries. Pertiment to the public health situation in the region is the status of women. In some counltries of the region, women's role In society does not allowed them to fully participate in de cision-nmaking. Nearly half the countries in the region have not ratified the convention on the eliinatioll of all forms of discrimination against women. This is of concern because the recognitioll of womliell's rights influences girls' education. Women's educational attainment lags behind that of men in most countries of the region, with the lowest female literacy rates in Egypt, Morocco and Yemell But other countries such as Jordan and Lebanon have impressive female literacy rates. About 25 percent of young girls in the region are currently illiterate One major challenge facing the region is increasing the educational attainment of girls, which is probably the single most effective investmiient a developing country can make towards economilc and social develo pment, given the host of positive benefits it creates for families, including better family health and nutritioll, improved birth spacing, and lower infant and child morbidity and mortality As womenl play major roles in raising children and caring for family members, their social status affects the health and well being of the famnly, and society as a whole Therefore, efforts at improving health will require a broad range of policy and program interventions including the education and empowerment of women. Emerging Challenge: HIV/AIDS The current health situation is also influenced by the emergence and re -emergence of infectIous diseases such as HIV/AIDS and Tuberculosis. Although HIV infection rates in the MENA region are relatively low, recent evidence suggests that new infections are on the rise and that HIV is spreading rapidly among the general population With aii estimated 80,000 new infectionis occuiTing in the region during the year 2000 alone, the number of adults and children living with HIV/AIDS reached 400,000 by the end of year 2000. This is an enormous increase In HIV infections compared to the estimated 20,000 new infections, which occurred in 1 999. Tuberculosis infection rates have also increased with the emergence of HIV/AIDS, and the highest rates are in Djibouti, Iraq, Morocco and Yemen In 1998, tuberculosis was the second leading cause of death, and HIV/AIDS was the third leading cause of morbidity among the most economlcally productivc age group (15 to 44 years) in the low- and middle-income countries of the Eastern Mediterranean region Public Health Activities in the Region Currently, most Bank-supported health activities in the region are focused on improving health systems and health services delivery. Provision of primary health care services is emphasized, which includes family planning, nutrition, maternal and child health services and control of infectious diseases. The MENA Region Health Group presently manages Fifteen health, nutrition and population projects in eight countries. Egypt, Iran, Jordan, Lebanon, Morocco, Yemen, Tunisia, and the West Bank & Gaza These projects address a broad range of health development issues including targeted interventions in family planning and communicable disease control (e.g, schistosomiasis control), strengthening hospital and clinical management capacity, upgrading health infrastructure and management infonnation systems; and health sector reform programs that encompass substantial restructuring of health care financing and del ivery systems. Preparation of new projects for health sector refonn and HIV/AIDS control are currently underway in Djibouti, Yemen and the West Bank & Gaza. The projects in Djibouti and Yemen are expected to begin in the year 2002. The HIV/AIDS project in Djiboutl is part of the World Bank's Multi -country AIDS program (MAP) for Africa, and is intended to support the development and implementation of Page viii community action programs to combat HIV/AIDS, and increase the availability of care for sexually transmitted infections (STIs) and HIV/AIDS opportunistic infections such as tuberculosis. There have been health sector assessment projects in the UAE, Saudi Arabia, Oman and Bahrain. The health sector development projects will assist the government with the sele ctive implementation of priority reforms targeted at improving the availability, quality and efficiency of health services in Djibouti and Yemen. Other areas of Bank assistance include human resource development, rationalization of the pharmaceutical sector, health financing and financial sustainability. Other organizations such as the WHO, UNICEF, UNAIDS and USAID have been involved in the promotion of the Expanded Program on Immunization (EPI), and the control of tuberculosis, malaria, schistosomiasis and other public health activities in conjunction with governments. Every country in the region has an active immunization program that is implemented by the government with the support of UNICEF and WHO. Other NGOs supported by USAID have been actively engaged in efforts to improve the status of women and the provision of reproductive health services in the region. Various non-governmental organizations (NGOs) and pnvate groups also provide health services in the region. For example, in the West Bank & Gaza, parallel networks have been operated by the Israeli Civil Administration, Palestinian NGOs and the United Nations Relief and Works Agency (UNRWA) to provide healthcare for Palestine Refugees. Activities of the Roll Back Malaria (RBM) program, a global partnership formed by WHO, UNICEF, UNDP and the World Bank, aim at, among many things, strengthening health systems to ensure adequate access to care by those suffering from malaria, started in the region in November 1998. The main elements of the RBM strategy include early detection and rapid treatment of cases, multiple and sustainable prevention strategies, focused research and well -coordinated interventions through dynamic global movement and partnership. The WHO also has an injury prevention prog ram that assists member countries in building capacity and locating support for injury control activities. Most countries of MENA have legislation to regulate the tar and nicotine levels of tobacco products produced in the various countries, and to prevent the sale of tobacco to minors Non-governmental organizations also play a relatively small role in tobacco control activities. Gaps Although governments and many international and local organizations have made efforts to improve health services and control communicable diseases in the region, very little attention has been paid to the increasing burden of chronic diseases and injuries, and emerging diseases such as HIV/AIDS. Considering current trends of disease burden, the stages of the various coun tries in the demographic and epidemiological transitions, and the high cost of treating chronic diseases and injuries, governments and other public health agencies in the region need to intensify efforts at preventing chronic diseases and injuries before they reach epidemic proportions and drain the health sector of scarce resources. Striking the right balance in addressing communicable diseases and issues related primarily to maternal and child health, and the health needs of the elderly and young adults who are most at risk for injuries, HIV/AIDS and chronic diseases in middle - and low- income countries present a major challenge to public health efforts, especially in countries where communicable diseases continue to be a major problem. Effective public health programs are an important means of reducing mortality and morbidity in a cost-effective manner. For example, interventions to prevent HIV/AIDS such as condom promotion, STD treatment, and AIDS prevention education programs, cost less than US$10 per HIV infection averted, compared to the hundreds of dollars that would be required to treat each case of HIV, and the ultimate loss of life and economic potential. Yet actual investments in these programs remain limited in many MENA countries. Effective public health programs require a comprehensive public health infrastructure. In most countries of the region, the public health infrastructure is often not well established, and not quite capable of performing the core functions Page ix of assessing, analyzing and monitoring the public health situation, assuring access to appropriate and cost-effective care, including health promotion, disease prevention services and healthy living conditions, and providing the basic information to support public health strategic planning and policy decisions. The public health agenda, if available, is also often not well developed, and may not benefit from adequate political commitment Public health leadership and well -trained public health personnel are limited Chronic disease and behavioral risk surveillance systems are often not available, and disease registries are incomplete. Thus, information on the incidenice of chronic diseases and injuries in the region is sparse. The maintenance of a reliable chronic disease registration system and injury surveillance system is technically complex and expensive However, it is necessary to invest in a regional health infonnation system to provide the knowledge base for regional public health strategies In many countries, there is a need for a comprehensive public health agenda, which reflects current trends in the demographic and epidemiological transitions. with due recognition for emerging and re-emerging diseases such as HIV/A1DS and Tuberculosis Since public health requires organized interdisciplinary efforts to address the physical, mcntal and environmental health concerns of communities, it is necessary to fonin partnerships with the various stakeholders and interest groups to develop a regional public health infrastructure General recomnmendations In all countries of the region, there is a need to. * Analyze current public health activities and develop a comprehensive public health agenda with set priorities; * Improve national and regional public health infrastructure and fo rn partnerships to address public health issues; * Strengthen public health leadership and capacity to perfonn core public health functions, * Develop policies for addressing priority public health needs at the national level taking into consideration the stages of the countries in the demographic and epidemiological transitions, * Allocate funds for public health activities within national budgets and prioritize public health activities identified as core issues in the various countries, to ensure optimum utilization of resources within constraints; * Establish disease surveillance and information systems to monitor the health situation: gather country-specific data on communicable and non-communicable diseases and injuries, and collate data at regional level for informing public health policy and strategies at both the regional and country levels; and * Intensify health promotion and disease prevention efforts, and develop the capacity to engage in related activities. Specific recommendations 1. Assure that a comprehensive public health agenda is an integral part of Health Sector Reforn (Health Systems and Health Financing Reforms); Page x 2. Target and implement cost-effective and integrated public health intervention programs to reduce: (a) vaccine preventable diseases through an intensified EPI program; and (b) communicable diseases (ARI, diarrhea, malaria and tuberculosis) through the provision of primary health care and social services such as improved water and sanitation facilities, and the implementation of effective environmental health policies, especially in the low- and lower middle-income countries of Djibouti, Yemen, Iraq, Morocco, and Egypt; 3. Strengthen health systems and improve basic health services delivery and accessibility, especially in the low- and middle-income countries of Djibouti, Yemen, Iraq, Morocco and Egypt. This might require restructuring of the health system, integration of basic public health services, and increasing public financing of basic public health services; 4. Implement appropriate nutrition intervention programs to improve nutritional status of children in the region, including breastfeeding promotion programs, behavior change communication (BCC) programs to improve infant feeding and childcare practices, and micronutnent (iron, iodine, vitamin A) intervention programs; 5. Implement culturally sensitive reproductive health policies aimed at reducing fertility and matemal mortality, and improving the status of women Specifically develop strategies to reduce adolescent fertility, make reproductive health services available and youth friendly, promote girls education and promote the participation of women in income generating and community development activities, and local decision -making; 6 Implement appropriate health promotion and disease prevention programs to reduce the incidence of expensive-to-treat communicable and non-communicable diseases in all countries, especially the middle-income countries of the region. These include: i) Promoting and supporting pattems of personal behavior and diet that can prevent chronic diseases from becoming epidemic; developing support at the primary care and community levels for handling chronic conditions; ii) Carrying out analyses for reorganizing health systems in lIght of the epidemiological transition. This would focus on infrastructure, package of services, quality and type of personnel, monitoring and evaluation systems, iii) Intensifying tobacco control activities by gamering political support for the implementation of effective tobacco control measures, and establishing regional and international collaboration to accelerate the development of effective tobacco control programs in the region; and Iv) Developing/intensifying HIV/AIDS prevention programs in all countries of the region, especially in Djibouti, where about 12 percent of the adult population is living with HIV/AIDS. 7 Strengthen injury prevention programs in all countries by building local capacity and locating support for injury prevention activities (liaise with WHO injury prevention program); 8. Develop national and regional communicable and non -communicable disease and injuries database as a knowledge base for informing national and regional public health strategies; Page xi 9 Develop national and regional public health infrastructure with govern ments, bilateral and non-governimienital agencies and local private organizations. This would include a) the training of public health personnel, b) development of public health leadership and the capacity to perform core public health functions of assessmen t, c) policy development and assurance, d) provision of the necessary resources and infrastructure to support public health activities; e) establishing diseases surveillance and inforimation systems; f) developing partnerships for addressing public health I ssues, and g) integration of national, regional and global strategies to address public healthi challenges of comimion concern Page xi i 1. Introduction Global efforts to improve the health of populations have achieved significant success during the past few decades. In most parts of the world, infant mortality rates are decreasing, and people are living longer as social and economic development improves, access to basic health services improves, and families become healthier. Many of the improvements in h ealth have been achieved through public health measures. Control of infectious diseases through immunizations, safe food, water and sanitation, and maternal and child health services are only a few of the public health achievements that have prevented countless deaths and improved quality of life. But in many countries, the success of public health has been taken for granted, and in others, the effectiveness of existing public health interventions have not been assessed. Health officials have difficulty communicating a sense of urgency about the need to maintain or intensify health promotion and disease prevention efforts, and to sustain the capability to meet future threats to the public's health. In most cases, it is difficult to determine the specific budgets allocated for public health activities (i.e., interventions as well as functions and infrastructure), and no explicit agenda exists for protecting and improving the health of the population. However, as countries go through the demographic and epidemiological transitions, disease profiles change, and the need for a comprehensive public health agenda becomes imperative. In recent times, increasing globalization of trade has increased intemational travel, diminished national borders and stimulated freer movement of people around the world. The rise of the Internet and recent advances in telecommunications have also boosted information exchanges across countries, reaching people everywhere, influencing their behavior and allowing them to lead more diverse lifestyles. This development brings to public health both challenges and opportunities to promote and protect health to which communities, govemments and international organizations must respond. For example, tuberculosis or HIV/AIDS control i n one country increasingly depends on improving control in the countries from which immigrants originate. In this context, it has become evident that public health efforts cannot be pursued in isolation. Interagency collaboration and integration of national, regional and global strategies to promote and protect the health of all people, and address health challenges of common concern have become a necessity. By definition, public health is what society does collectively to assure conditions in which peop le can be healthy.' Its mission is achieved through the application of health promotion and disease prevention technologies and interventions designed to improve and enhance quality of life. These activities encompass a broad array of functions and exper tise, the core of which are: (a) assessment;' (b) policy development;" and (c) assurance "' Essential public health functions are a set of indispensable activities which must be carried out in order to protect the health of communities through means that are targeted at the environment and the community. Specifically, they must address the following: (a) prevent epidemics and the spread of disease; (b) protect the population against environmental hazards; (c) prevent injuries; (d) encourage healthy behavio rs; (e) respond to emergency situations (natural disasters, etc); and (f) ensure quality of and access to health services. The concept of essential public health functions was developed and adopted by the WHO as part of the "Health-for-All" policy for the 215' century,2,3 to enable governments to deliver Assessing and monitonng the health of populations at nsk to identify health problems and priorities, Fonmulating public health policies, in collaboration with community and govemnment I eaders, designed to solve identified local and national health problems and priorities, "' Assuring that all populations have access to appropnate and cost -effective care, including health promotion and disease prevention services, either by providing services directly, encouraging actions by other entities (public or private) or by regulation Page I sound public health policies for addressing emerging and priority needs in an optimum1l way Governments who want to provide services to needy populations are often faced with difficult policy options regarding the choice of interventions, financing and provision of services and are especially hindered by financial constraints. The role of development agencies, includilg the WHO and World Bank, is to assist govenmments in making those choices in a sustainab le way. For the World Bank's operational purposes, major public health functions are grouped into five categories (a) policy development; (b) creation and dissemination of evidence for health policies, strategies and actions, (c) prevention and control of disease; (d) inter-sectoral action for better health; and (e) human resource development and capacity building A wide range of activities fall within these basic categories of public health functions, such as surveillance, regulation, evaluation, disease prevention and control and workforce development. The classification of public health functions into a limited number of categories helps to define essential public health functions within each country context, assess public health performance gaps an d estimate financial investment needs in public health. While monitoring of all public health functions must be in the purview of government agencies, their implementation need not be the sole responsibility of governments, but also that of private organizations, other public agencies and the community at large. The role of the government in assuring that the overall system works, however, is indispensable. Assuring the financinig of public health functions primarily rests with the government with the su pport of non-governmental and international organizations and private agencies. An effective public health system at the local, national or regional level requires a comprehensive public health infrastructure, which is a complex web of practices, institutions and resources necessary for the delivery of public health services. 4 The public health infrastructure consists of the workforce, data and information systems, governmental and non -governmental organizationis and other private and public agencies, and serves as the foundation for planning, delivering and evaluating public health interventions. It requires health professionals who are competent in cross - cutting and technical skills, public health agencies with the capacity to assess and respond to community needs, and up-to-date information systems. A strong infrastructure provides the capacity to prepare for and respond to various threats to the health of the population, which assures a favorable environment for economic and social development. This paper aims at reviewing the public health situation in the MENA region, examining changes in the demographic and epidemiological profiles of countries to the extent that is possible givell data limitations, assessing the public health activities that have b een undertaken to protect and promote health in the region, identifying gaps in current efforts, and recommending appropriate strategies for addressing the public health issues identified. It is expected to provide governments with the basic mformation they need to respond to the challenges created by the health transition in the context of budget constraints and globalization The analysis should also provide a lens through which appropriate decisions can be made to meet the future demands of public hea Ith care in the region. Page 2 Box 1 ESSENTIAL PUBLIC HEALTH SERVICES Essential Public Health Services 1 Monitor health status to identify community health problems. 2. Diagnose and investigate health problems and health hazanis in the oommunity. 3. Inform, educate, and empower people about health issues. 4- Mobilize community partnerships to identify ancd solve health problems. 5. Develop policies and plans that suppoft individual and community health efforts. S. Enfor-ce laws and regulations that protect health and assure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8 Assure a competent public health and personal health care wo rlkforce. 9. Evaluate effecliveness, acoessibility, and quality of personal and population-based health services. 10 Research for new Insights and innovative solutions to health problems. Source: Public Health Functions Steering Committee. Public HeaffTh in Arnernca, Fall 1994. httpU.1www.health govrphfunctEons/public. htm (January 1. 2000). Box 2 PUBLIC HEALTH FUNCTIONS AND EXAMPLES OF ACTIVITIES 1. Policy developinent - Public health regulation and enforcement* - Evaluation and promotion of equitable access to necessary health services* - Ensuring the quality of personal and population -based health services* - Health policy formulation and planning - Financing and management of health services - Pharmaceutical policy, regulation and enforcement 2. Evidencefor public health policies, strategies, and actions - Health situation monitoring and analysis* - Research, development, and implementation of innovative public health solutions * - Provision of information to consumers, providers, policymakers and fin anciers - Health information and management systems - Research and evaluation 3. Prevention and control of disease - Surveillance and control of risks and damages in public health* - Management of communicable and non communicable diseases - Health promotion* - Behavior change interventions for disease prevention and control - Social participation and empowerment of citizens in health* - Reducing the impact of emergencies and disasters on health* 4. Intersectoral action for better health - Environmental protection and health, includinig road safety, indoor air pollution, water and sanitation, and vector control in infrastructure, management of medical wastes, tobacco legislation, school health/education 5. Human resource development and capacity buildingfor public health - Development of policy, planning, and managenal capacity * - Human resources development and training in public health* - Community capacity building. * Same as PAHO/CDC/WHO "essential" public health functions (PAHO, May 2000). Page 3 2. Regional Context 2.1 Economic, Political and Social The MENA"' regioni covers a geopolitical strategic area with a generally arid and harshi climate and abundant natural resource v Over half of the count-ies in the regioii have significanit oil reserves, with the region accounting for 31 percent of world oil production in 1997.5 While sharing the predominance of Islamic culture and the Arabic language (except for Farsi in Iran), the coulitries are heterogeneous in termis of ethnic composition, political orieitationl and economic develo pmclt levels The region encompasses oil exportiing countries of the Gulf Cooperation CoIncil (GCC), whichi are among the wealthiest countries in the world, and countries stich as Yemenl and Djibouti, which are among the poorest in the world . Most countries in the region fall within the lower middle-incomile range, though large income disparities exist within each countly. " Per capita income raniges from US$350 in Yemen to more than US$19,000 in Kuwait, with a regional average of $2,060 in 1999 (excluding the Gulf States), whicil compares favorably with an average of $2,000 for middle-incomile couitries (appendix I) The oil boom of the 1970s gave a major boost to economil1c growth in the region, which wvas also beneficial to the noni-oil producing countries, particularly due to revenues earned throughi labor markets The mid-1980s saw major economic, political and social chaniges in the regioni Economliic growth slowed as oil prices fell, and recession in oil -exporting countries had repercussions in the rest of the region, particularly with the return of large numlibers of migr-anlt worker-s While family resouices for traditional safety nets dwindled due to falling remittaicecs, unemploymenit rates increased. At the same time, MENA countries faced increasing competition from other regions, for example, the emerging economies of East Asia, Eastern- Europe and forimler Soviet Republics and the establishment of the European Union These global changes created opportunities as well as challenges to the region's economic growth The real per capita income for the regioni was projected to grow at just 0 4 percent per year during the mid - I 980s, the lowest among the developing regionis of the world. A number of count-ies in the region (Iran, Iraq and Libya) also faced varying degrees of economic sanctions that adversely affected development in the region6 Other activities such as wars, regional conflicts and natural disasters have also affected development in the region Following ilcarly a decade of low and declining growth in the 1980s, economies of the MENA region began to implement stabilization and structural adjustment measures to enhanice the role of market forces, promote a dynamic private sector and accelerate openness to the globa I economliy During the 1990s, tighter demand management, trade liberalizationi, and improved regulatory refon-n measures helped improve economic perfonnance in most economies of the region. By the latter half of the 1990s, most economies in the region succeeded in stabilizing the macroeconiomy fiscal deficits declined by half, countries such as Yemen, Algeria and Lebanon demolistrated significant progress in reducing inflation and current account balances improved dramatically ' Countries in this region include Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan. Kuwait, Lebanon, Libya. Morocco, Omani. Qatar, Saudi Arabia, Syria, Tunis ia, United Arab Emirates, Wcst Bank & Gaza and Yemell ' The countrics are grouped by economic strength as follows countries of the oil exportlig GCC coimpi isinig of Bahliain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates are categorized as upper middle- or high-incomiie countries, based on their GDP per capita Algeiia, Egypt, Iran, Iraq, Jordan, Lebanoni, Morocco, Syria, Tunisia and \Vcst Bank & Gaza are considered to be lower middle-income countries Yemen and Djibouti, the least deeveloped coulitr ies in the region, are the considcrcd to be low-income countries Page 4 across the board. Average annual GNP growth during the 1990s was slightly more than 3 percent, compared with 2.1 percent growth in the 1980s. 7 In 1999, the region's fiscal and current account balances improved, owing mainly to higher oil prices. Regional GDP growth was 2.2 percent for the year, with considerable differences across countries. For major oil exporters, fiscal prudence and lower oil export volume held growth to 1.5 percent. More populated oil exporters (Algeria and Iran) fared slightly better with 2.7 percent growth, although drought in Iran hurt agricultural incomes and raised inflationary pressures. The more diversified economies of Jordan, Morocco, and Syria also suffered from drought but managed growth of nearly 3 percent. Growth was significantly higher in Egypt and Tunisia (5 to 6 percent) following the recovery of traditional markets and a rise in tourism. 7 Despite these improvements, important challenges remain. Faster GDP growth is required to reduce unemployment and provide jobs for over one million young people entering the region's labor markets annually. The public sector remains large, even in countries such as Jordan, Morocco, and Tunisia that have initiated reforms to reduce the scope and improve the efficle ncy of public administration. Integration with the global economy lags well behind other developing economies in East Asia and Latin America. Furthermore, the fragility of the natural environment threatens to constrain economic growth, and absolute poverty is on the rise in some countries, as is the number of economically vulnerable groups.7 2.1.1. Urbanization The growth of urban areas and the decline of rural areas has been a general pattern throughout the developing regions of the world The complex multivariate nature of all the possible interactions between risk behaviors and the socioeconomic environment associated with rural -urban migration does not lend itself to any simple explanation of the positive or ne gative impact of urbanization on health The long-term effect of this rural to urban settlement pattern, however, increases the disease burden for urban areas. Almost 60 percent of the population of MENA lives in urban areas (table 1). Apart from Egypt and Yemen, which have more than 50 percent of their population living in rural areas, every country in the region has at least half of its population urbanized. Kuwait, for example, is completely urbanized with 97 percent of its population living in urban areas, with universal access to safe water, sanitation and health facilities. There are significant gaps between urban and rural areas in terms of access to and quality of health and social services, and the gaps are particularly large within lower -income countries. 2.1.2. Health and Social Services Prior to the 1 970s, access to modem health care and basic social services was limited to populations in urban centers. Many countries had no functional health system. The advent of oil wealth contributed to the expansion of social services and infrastructure, development and expansion of health systems, and significant reductions in mortality levels. 6 For example, infant mortality rates declined from a regional average of 137 deaths per 1,000 live births in 1970 to 45 per 1,000 live births in 1998. Following the collapse of the oil boom, economic stagnation heightened the macro distortions and micro inefficiencies created by past policies and investments. In general, central governments occupied a preeminent role in economic and social development; governance was highly centralized and investments in social services emphasized the expansion of infrastructure over concerns for quality, efficiency and sustainability The governments in many countries in the region remained basically centrist in orientation. The structural rigidities inherent in such a system explains, in part, the difficulty governments faced in responding flexibly to fiscal constraints and the changing needs of the population. Rapidly expanding populations imposed Page 5 heavy financial burdens while public resources were unable to respond to competing investmeint needs in all sectors. The inability of the public sector to secure sufficient fundinig or maniag e limited resources efficiently, and to offer quality services encouraged the expansioni of private sector services, but these services remained largely unregulated. Some governments began to take steps toward structural reforms aimed at reducing macroecon omic inefficienciles in the system 2.1.3. Water and Sanitation The health of a population is often influenced by the environment in which it lives Lack of ciean water and basic sanitation are the main reasons why infectious diseases are so comillon in developing countries. According to the World Development Report (1993),' inadequate water supply alone causes diseases that account for 10 percent of the total disease burden in developing countries To date, however, many countries in the MENA region still lack adequate water and sanitation facilities, and efforts to improve the provision of water, sanitation and drainage have been quite disappointinig. While couitries such as Kuwait and Jordan have excellent access to clean water and sanitation facilities, less than 70 percent of the population in Morocco aiid Yemen have access to these services (table 1) Although 90 percent of the population of Djibouti has access to clean water supply, only 55 percent of the population have access to sanitation facilities West Bank & Gaza has the worst sanitation with only 31 percent of the population having access to adequate sanitation facilities Most water and sanitation facilities are concentrated In Lirbani areas, although 42 percent of the population in the region live s in rural areas. 2.1.4. Education Education, an aspect of socioeconomic development that significantly impacts health status, Is quite advanced in the MENA region The past few decades have seen remarkable expansions in access to basic education throughout the region.5 Net primary school enrollmentv" ranges from 58 percent in Yemen to 98 percent in the UAE, with a regional average of about 87 percent (table I) Countries such as Algeria, Egypt, Syria and Tunisia have high primary school enrollenit rates (90 to 96 percent), however, secondary school enrollment is poor Most countries are now poised to further increase access to secondary and higher education, and to effect dramatic improvements in the quality of education offered at all levels. In many countries of the region, adult literacy rates are low, and women's educational attainment lags behind that of men. Gender disparities in educatiol hamper improvements in women's health and social status. Egypt, Iraq, Morocco and Yemen have the highest youth and adult illiteracy rates The regional female illiteracy rate is about 48 percent, declining from 52 percent in 1995, while male illiteracy remains at a relatively low 26 percent About 25 percent of young girls are currently illiterate One major challenge facing the region is to increase the educational attainment of females. Girls' education is probably the single most effective investment a developing country can make, given the host of positive benefits it creates for families, including better family health and nutrition, improved birth spacing, lower infant and child mortality and morbidity. s A 10 percentage point increase in girls' primary school enroll inent decreases infant morality by 4.1 deaths per 1,000 live births, and a similar rise in girl's secondary enrollnent by another 5 6 deaths per 1,000 live births.9 Net enrollment ratio is the ratio ofthe number of children of official school age (as defined by the national education system) who are enrolled in school to the population of the co rresponding offficial school age Page 6 There are efforts to improve girls' education in some countries of the region. Iran is pro moting education for women and girls in rural areas, with girls' primary school attendance now over 90 percent. Programs in Egypt, Morocco, Tunisia and Yemen are bringing education to girls in poor areas through community schools located closer to their h omes. In Egypt, for example, the community schools which began through strong partnerships among the Ministry of Education, communities, NGOs and UNICEF are based on the principle of community ownership. These schools, which target girls in deprived rural hamlets, employ a model of active learning which fosters creativity, critical thinking and problem -solving skills as the basis for lifelong learming. TABLE 1: ACCESS TO HEALTH AND SOCIAL SERVICES Urban Access to Access to Net primary Youth Adult population safe water sanztation school illiteracy rate illiteracy rate (% (% of (% of enrollment (% aged (% of people Country of total) population) population) (%) 15- 24) 15 & above) 1998a 1998' I_ 99b 1990-1998' 1990-19984 1990-1999"' Male Femalale le |Female Low-Income Djibouti 82* 90 55 - ]| |60*T 33* Yemen j 24 61 | 66 58 18 58 34 77 Lower Middle-Income Algeria 60 90 91 94 8 18 24 46 Egypt 45 87 77 92 24 40 35 58 Iran 61 99 81 96 4 10 18 33 Iraq - 81 75 90 23 36 36 _57 Jordan 74 97 99 86 I 1 6 17 Lebanon 89 94 97 91 3 8 9 21 Libya 97 98 96 0 8 10 35 Morocco 55 65 58 70 25 45 40 66 Syria 54 88 80 94 5 23 13 42 Tunisia 65 98 80 96 3 13 21 42 West Bank and Gaza 84 31 - ner Middle-Income Bahrain 94 97 Kuwait 97 100 100 87 9 8 17 22 Oman 85 78 86 1 6 22 43 Saudi Arabia 85 95 86 76 5 11 17 36 United Arab Emirates 97 92 98 15 6 27 23 MENA regional 58 87 13 25 26 48 average I I _ _ _ _ _ Souirce 'Data are for the most recent year available World Development Indicators World Development Report 2000/2001 World Bank, Washington DC *UNAIDS/WHO Epidemiological Fact Sheet. 2000 Update 2.2. Demographic Profile With about 300 million people, the population of MENA is currently growing at an an nual percentage rate of 2.2 percent, declining from 2.6 percent in 1995. Although the region is middle - income, its demographic profile is more reflective of a low -income region, characterized by high rates of fertility and population growth. Population growth rates vary from 1.1 percent per year in Kuwait to 4.4 percent in Jordan (table 2). Saudi Arabia, which is an upper middle -income country, has a very high rate of population growth that is almost similar to that of Yemen, the poorest country in the region The average total fertility rate is 3.9 children per woman, ranging from 2 2 in Tunisia to 6.3 in Yemen Saudi Arabia also has one of the highest fertility rates (5.7), with Syria, Oman and Jordan ranging between 4.0 and 4.6 births per woman Page 7 Despite recent fertility declines in many countries of the region, because of the population momentum, many countries will continue to have relatively high population growth rates over the next 20 years It is estimated that by 2015, the number of adults in the region will increase by 140 percent '° This represents the highest adult population growth in the world after sub -Saharan Africa Several lower -middle-income countries in the region will have 5 percent or more of their populations over age 65, and the challenges of an aging population will become prominent These challenges include a substantial nse in non -communicable diseases and injuries, and demand for long - term care An aging population with increasing chronic diseases and injuries will have a signiificant impact on health care costs and demands in the future. These problems are beginning to be felt in some of the high-income countries of the Gulf States. Rapid cost explosion is already becominlg an important feature of health systems in these countries "' TABLE 2. DEMOGRAPIHIC PROFILE Population Annual Crude birthI Crude deatih Total under age 18 population rate rate Population aged Countitr population years Growthl Rate Totalfertility' per 1,000 per 1,000 65 and above a (millions) (,nil/ions) (%) rate popuilatioi population % of total 1999 j 1998 1990_1999h 1998b 1998' 1998" 1998 2015 Lows-Income D1ibouti 0 6 | | 2 3* 53* [ 37* 15 | | Ycmen 170 j 92 40 63 f 40 12 30 24 Lower Middle-Income Algeria 305 134 22 35 26 6 38 47 Egypt 62 4 28 6 1 9 3 2 24 7 4 4 5 5 Iran 630 304 1 6 27 22 5 46 50 Iraq 228 106 20 46 32 10 3 1 42 Jordan 47 3 1 44 4 1 31 4 29 4 1 Lebanon 4 2 1 2 1 8 2 4 21 6 5 7 5 9 Libya 54 25 -- 37 29 4 30 50 Morocco 282 110 1 8 30 25 7 43 52 Syria 15 7 7 7 2 8 4 0 29 5 -- Tunisla 9 5 3 6 1 6 2 2 18 6 5 6 6 5 Wcst Bank & Gaza 2 7 3 5 5 9 42 5 3 5 2 8 ._____ _____ _____ __________ _Upper M iddle-lncome Bahraiii 07 24 26 19 4 22 Oman 23 1 2 -- 46 29 _ 3 26 46 Saudi Arabia 214 9 6 3 4 5 7 34 4 2 8 4 4 Kuwait 1 9 0 8 -II 2 8 23 2 1 9 4 8 United Arab Emirates 2 8 0 8 3 4 17 3 2 1 8 3 MENA regional 290.9 -- 2.2 3.9 27 7 3.4 4.9 averages I _I_I_I Soti,ce d World Bank Estimates WDI 2001 'World Development Indicators World Development Report 2000/2001 World Bdnk, Washiigton DC *UNAIDS/WHO Epidemiological Fact Shect 2000 Update Page 8 3. Health Systems in MENA Despite improvements in health status in MENA, many childhood deaths still occur in the low - income countries of the region due to malnutrition, vaccine-preventable diseases and other infectious diseases such as diarrhea and ALRI International experience indicates that although the underlying cause of these problems are well known and interventions are often av ailable, potentially effective policies and programs often fail to reach the needy populations because of weaknesses in the core functions of health systems. Health systems in the region reflect the very different levels of economic development of the countries, and can be grouped into four categories. low-income, middle-income, the Gulf States, and the special cases of countries that have undergone major political upheavals or changes, such as Iraq, Lebanon and West Bank & Gaza. Yemen and Djibouti, the poorest countries in the region, have a two-tiered health system typical of very low-income countries. The first tier consists of subsidized, limited and often low quality services provided by the central government and financed out of general revenues. The second tier is made up of a large number of small, private providers and NGOs financed by direct out-of-pocket payments by households and/or donor assistance. The lower middle-income countnes in the region (Algeria, Egypt, Iran, Iraq, Jordan, Lebanon, Morocco, Syria, Tunisia and West Bank & Gaza) have developed pluralistic systems of financing and delivering health services, typically through traditional Ministry of Health -based systems and parallel and frequently uncoordinated social health insurance-based systems. The upper middle-income oil exporting countries of the Gulf (Kuwait, Oman, Qatar, Saudi Arabia and UAE) have health systems that offer free or highly subsidized care financed primarily from general revenues. Lebanon and the Palestinian Administration are special cases where past political circumstances prevented government from playing a major role in the development of the health system. Lebanon has a network of private providers that caters largely to the needs of the relatively well -to-do populations in urban areas, whereas the poor have very little access to care. Lebanon has among the highest bed -per-population ratio in the region (4 beds per 1,000 population). Yet govemment services do not reach rural communities which, therefore, must depend on various NGOs and other pnvate groups for services. Despite the wide range of approaches, virtually all these systems suffer from many of the same types of problems and challenges, including. periodic systemic shocks due to political ins tability; rapidly growing populations; dual (communicable and non -communicable) disease burdens; lack of a comprehensive public health agenda and strategy; absence of a specific budget for public health activities, poor health outcomes for moneys spent; imbalances in the public-private mix in financing and delivery of health services leading to access and equity problems, lack of coordination between public and private delivery systems resulting in inefficient use of combined public and private delivery capacity and cost escalation; quality problems in both public and private sector delivery, and lack of long-term financial sustainability. 3.1. Performance of MENA Health Systems There is wide variation in the performance of health systems in the MENA region, even among countries with similar levels of income and health expenditure. ] The performance of a health system is assessed by the ratio of achieved levels of health to the levels of health that could be achieved by the most efficient health system. For example, the relatively poor health systems of some countries in the region, such as Djibouti, is reflected in its inability to provide even half of its young children with immunization services, as well as poor access to and quality of maternal health services, resulting in the highest maternal mortality rates in the region. On the other hand, Oman, Page 9 with a very good health system, has excellent immunization rates, low maternal mortality ratios and a high proportion of deliveries assisted by health personine 1. The performance of the health system of a country, therefore, impacts the heath status of its population. However, improvemilents in health systems and health services alone are not sufficient for addressing public health issues, and do not necessarily translate to improved public health status. For example, despite its excellent health system, levels of child malnutrition, low birth weight and maternal anemia, which are indicators of maternal and child health, are relatively high in Oman, and are compa rable to lower middle-income countries such as Egypt and Morocco Other public health interventions, such as women's education, improving access to basic social services, as well as the active promotion of disease prevention and health promotion activities at the community level, are essential for ensuring adequate health for all. Effective care for chronic conditions also requires changes in the performance of health systems at various levels, i e., health policy, healthcare organizationi, professional, community and patient levels 3.2. Health Services Infrastructure, Resources and Capacity Health service use and costs depend heavily on existing health infrastructures. Appendix 2 contains information on the number of physicians and hospital beds per 1,00 0 population Generally, these measures of health service capacity increase with income, but there is considerable variationi at any given income level. The number of physicians varies from 0.1 per 1,000 population in Djibouti to 2.3 per 1,000 in Lebanon The number of hospital beds varies from 0 6 per 1,000 population in Yemen to 4.3 in Libya. These indicators measure the supply of health services but do not provide any infor-mation about access, quality, efficiency, effectiveness, type, availability and level of training of personnel providing public health services, or appropriateness of geographical and specialty distributions Nor do they provide information about how the consumption of health services differs among groups within countries, regions o r communities. Detailed analyses of utilization rates and costs indicate that many health systems in the MENA region suffer from inefficiencies and poor quality due to under-finanicing For example, in many countries there are large surpluses of hospital beds and physicians (e.g., hospital bed occupancy rates in most countries in the region are below 60 percent), yet poor quality and insufficient numbers of skilled nurses These problems reflect the legacies of earlier investment strategies that focused on numbers rather than the quality of inputs, with relatively little attention to sustainability, appropriateness to local conditions and the changing burden of disease 3.3. Health Expenditures and Financing The MENA region on average spends about US$117 per c apita on health services (appendix 3), the third highest among the low- and middle-income regions, after Latin America and Eastern Europe and Central Asia As a share of total income, MENA on average spends nearly 5 percent of GDP on health care (appendix 3) of which 50 percent is from public sources Health expenditures vary from 3 3 percent of GDP in Kuwait to 12 3 percent in Lebanon, and percentage of total health spending from public sources ranges from 30 percent in Lebanon to 80 percent or more in 0 man, Saudi Arabia, Kuwait, and UAE "v This spending pattern is typical of middle-income countries Some countries such as Lebanon, Jordan and WBG spend larger shares of their income on health '" The figure on private spenidinig in UAE should be viewed with cauitioi, sice It is based on a profcssional estimate and not on survey data Page 10 than some OECD countries, spending levels that are not likely t o be sustainable or affordable in the face of the epideiniological transition. Nonetheless, evidence from national health accounts data indicate that not enough provision is made for health promotion and disease prevention activities to reduce the incidence of chronic disease and injuries within national health budgets in almost all countries of the region. Health expenditures are highly correlated with individual country's incomes (figure 1). Global trends suggest that as incomes rise, health expenditure s increase as a share of GDP, as does the public share of health spending. The mean health expenditure per capita in the MENA region is US$117, ranging from US$666 in Kuwait to US$20 in Yemen. This figure (US$117), though low compared to Europe and Latin America, should be adequate to secure minimum preventive and essential clinical services. In many developing countries, the amount spent per capita on health is much less than the estimated US$12 a year needed to secure the minimum preventive and essenti al clinical services Yemen's health expenditure per capita (US$18) is 165 percent of the estimated US$12 a year needed for minimum preventive and essential clinical services. Hence the constraint to providing adequate essential public health services in all countries of the region is not necessarily a lack of resources, but an absence of an explicit public health agenda, weak public health infrastructure and insufficient political commitment to provide the necessary services. 3.3.1. Public Health Financing Financing of public health activities in most developing countries has traditionally been inadequate. Health expenditures are basically focused on curative and hospital care with little attention to public health interventions, which tend to have greater extemalities and yield greater benefits at lower cost. Expenditure on essential public health services are usually categorized as follows: * Control of vaccine preventable diseases through immunization; * Control of communicable diseases; * Matemal and child health care; * Family planning/reproductive health; * Health education for diseases prevention and health promotion; * Environmental sanitation and hygiene; * Early detection (secondary prevention) of chronic diseases such as cancers, cardiovascular diseases and mental illness; and * Public health infrastructure development and maintenance. Financing of these activities can be organized along a spectrum, from pure public goods to mixed and private goods (appendix 4) It will be up to governments to decide where to draw the line along this spectrum in the financing of these services, according to the resources available. In most MENA countries, financing of public health services are largely limited to the provision of highly cost-effective services primarily relating to maternal and child health such as immunization, antenatal care, control of communicable diseases and health education relating to these, with relatively little support for chronic diseases and injuries, emerging diseases such as HIV/AIDS, and the development and maintenance of public health infrastructure Page I I Barriers to adequate resource allocation for public health activities include the following * Absence of an explicit criteria for allocation of health resources both for public health activities and essential public health functions; * The perception that public health is limited to prevcntive services, * Poor tracking of public health functions, activities and their funding sources; * Limited information on sources of finance for public health activities in the private sector, * Limited information on health-related activities of the private sector; * Poor access to informiationi on public health functions that fall outside the responsibilities of the health sector, such as the environment, water and sanitation. Such infonration is extremely relevant to public health resource allocation since they are major determinanits of public health. 3.3.2. National Health Accounts (NHIA) To cnable the public health community to examine and understanid its own strengths and weaknesses, and to communicate to policy makers and other partners the need for developing and maintaining a public health infrastructure, it is necessary to document public health expenditures (from both public and private sources) and resource allocations for essential public health services National health accounts track resource inputs to the health sector, and describe expenditures on1 health including both public and private expenditures. By contrast with industrialized countries, few developing countries have health accounts that are comprehensive and methodologically consistent with national health accounting approaches.'2 Only a few countries in the MENA region havc a well-developed NHA system (see section 5.3.3 for these countries) The absence of consistent NHAs in many countries in MENA makcs cross-country comparisons of health spending difficult. 16.0% 1 4.0 % C~ _ 12.0% 10 0 8 10.0% * * 6 8.0% __** S ,*- 3 6. 0%- o _ _ _ _ _*._ _* _ ~' 0°/ 4.0% .~~~~~~~~ O 2.0% 0.0 100 1,000 10,000 100,000 per capita GDP, USs FIGURE IA: HEALTH EXPENDITURES AS PERCENT OF GDP GLOBAL TRENDS, MID 1990S Page 12 Health expenditure as a % of GDP 0 ~~ P 000 0 0 0~ 0 rr X > X5. ~ ~ ~ ~ 4 0* C -I-,- e c~~~ **I ---1- o0 . ,zg_ 0 _ I _*_/s ______ _ +___ 4. Public Health Situation Signilficant improvements in health status, morbidity and mortality have been achieved In MENA over the last twenty years, largely through improvemenits in technology, education and socioeconomic development, as well as the expansion of health services and piblic health programs Life expectancy at birth has on average increased in most countries to a current regional estimate of 68 years, ranging from 50 years in Djibouti to 77 years in Kuwait. Infant mortality rates have deciined to 45 deaths per 1,000 live births on average, from an estimated 54 per 1,000 live births in 1995. Iraq is an exception with the highest infant mortality rate of 103 deaths per 1,000 due to deteriorating health conditions as a result of economic sanctions Imposed about a decade ago Despite the overall improvements in living standards and health services In tihe region, wide disparities in health status persist For example, Infant mortality rates vary from 8 deaths per 1,000 live births in UAE to over 100 in Djibouti and Iraq. Under-five mortality rates vary from 8 in UAE to 125 deaths per 1,000 live births in Iraq, with most countries falling within the range of 10 to 60 deaths per 1,000 live births. With regard to adult mortality, the probability of dying for males aged 15-60 varies from 335 deaths per 1,000 adults in Yemen to 125 in Kuwait, while for females the probability of dying varies from 331 deaths per 1,000 adults in Yemen to 65 In Kuwait These disparities are influenced by differences in the levels of socioeconomic development and access to health services Some countnes such as Yemenl and parts of Egypt and Morocco continue to suffer from high mortality rates from infectious diseases, especially among women and children. TABLE 3. HEALTH STATUS INDICATORS Proportion Adult mnortahltj Life Injant Under-S of children rate' C'ountry aTotal GNP expectancy at niortahity mortalty unider age 5 (per 1000 adults, Coantr' population per capita birthi rate a rate inalnourishied aged 15-60) (millolls) (USS,) (years) Per 1000 live Per 1000 (Y.) I_b 9y9 h 7 999b 1998' births 1998' 1998' 1990-1999Y Males Females Low-lncome Djibouti | 0 6 | 790 50 l Ill I - - Yemen | 17 0 350 56 | 82 1 96 46 335 331 Lower Mlddle-Income Algeria 30 5 1,550 71 35 40 13 158 123 Egypt 62 4 1,400 67 49 59 12 195 171 Iran 63 0 1,760 71 26 33 16 161 150 Iraq 228 59 103 125 23 197 171 Jordan 47 1,500 71 27 31 5 158 119 Lebanon 4 2 3,700 70 27 30 3 176 132 L-bya 5 4 5,540 70 23 27 5 185 129 Morocco 28 2 1,240 67 49 61 10 203 147 Syria 15 7 970 69 28 32 13 203 138 Tunisia 9 5 2,100 72 28 32 9 166 142 West Bank & Gaza 2 7 1.610 71 24 26 167 109 Upper ____ldde-Income Bahran 0 7 73 9 22 175 104 Kowailt 1 9 20,190 77 12 13 2 125 65 Omani 2 3 4,940 73 18 25 23 141 106 Saudi Arabia 214 6,910 72 20 26 14 165 138 United Arab Emirates 2 8 17,870 75 8 10 7 127 92 MENA regional average 290.9 2,060 68 45 55 15 175 138 Sooce ' World Bank Estimates, 2000 b World Developmeint Indicators In World Development Report 2000/2001 World Banik WHO Eastern Mediterranean Region Country profiles hittp //vww who sci eg/tierinfo/eimir countites htim Laot updated 25 Septembher 2000 Fgwie itn itallif ape fot vears ot/tel thtait those specified Page 14 4.1. Nutrition Although the nutritional status of people in MENA has shown improvement over the last two decades, malnutrition remains a major public health problem. 13 Levels of malnutrition vary tremendously within the region The proportion of children under age 5 who are malnourished varies from 2 percent in Kuwait to 46 percent in Yemen with a regional average of 15 percent. In seven countries of the region, over 20 percent of children under five years of age are stunt ed, and about 24 percent of children in the region are wasted (table 4) In fact, malnutrition appears to be increasing in several countries of the region Algeria, Egypt, Tunisia and Morocco. The prevalence of low birth weight deliveries varies from 2 percent in Jordan to 24 percent in Iraq, with a regional average of 10 percent In at least five countries of the region, over 10 percent of babies are bom with low birth weight (i.e., <2.5 kg), a situation that is indicative of poor nutntional status of mothers. Apart from Yemen and Iraq, most countries in the region have achieved food security at the national level, especially in terms of energy intake. Despite high food security, and over -nutrition in some cases, overt under-nutrition persists, and deficiencies of micronutrients such as iron, iodine and vitamin D continue to be common in some poor countries. Anemia is widespread among women and children. Maternal anemia prevalence rates range from 17 percent in Iran to as high as 54 percent among pregnant women in Oman, with a regional prevalence rate of 29 percent, which is quite high compared to other middle-income areas It is estimated that about 85 million people are at risk for iodine deficiency disorders (IDD), which are particularly common in Yemen, Syria, Iran and parts of Egypt. Vitamin D deficiency has also been reported among women and children in Iran, Kuwait, Libya, Morocco, Saudi Arabia, West Bank and Gaza and Yemen. Although the dynamics of the demographic and epidemiological tra nsitions have long been recognized, only recently has it been realized that concurrent changes in nutrition also occur with improvements in socioeconomic development, with equally important implications for resource allocation and public health strategies. These changes, referred to as the nutrition transition, lead to a marked shift in the structure of diet and the distribution of body composition. 14 Although poverty is directly linked to malnutrition, economic prosperity does not necessarily translate in to improved nutrition For example, in Egypt and Tunisia, prevalence of stunting increased despite a rise in GNP per capita. Improvements in economic development in the MENA region have initiated a nutrition transition. Diets are changing from a predomi nantly, cereal and vegetable base with relatively low caloric intake to a high fat, high -protein diet. Changes in diet and lifestyle resulting from economic prosperity and rising income levels, have caused an increase in the incidence of obesity and other diet-related, non-communicable diseases such as coronary heart disease and diabetes mellitus. Although data on this condition is scarce, childhood obesity has been recorded in significant numbers in Tunisia and Morocco. In Jordan, 68 percent of the adul t population aged over 24 years are reported to be obese (BMI > 25 kg/Mi2), 46 percent have high cholesterol levels and 17 percent are diabetic. I5 Behavioral factors such as weaning practices and breastfeeding play a critical role in determining the nutritional status of children, as do infectious diseases, sanitation and the availability of potable water Other factors such as mode of food preparation and intra -household food distribution also contribute to malnutrition. Poor bioavailability of micronutri ents in the diet is a key contributor to micronutrient deficiencies. Many countries in the region are implementing universal salt iodization programs. However, in most of these countries, coverage is not adequate. Further technical inputs and multisectoral commitment may be required to achieve sufficient coverage of iodized salt. An important source of vitamin D is sunshine. Humans can produce vitamin D if their skin is exposed to sunlight. However, cultural practices prevailing in the region such as the veiling of women and Page 15 constant covering of infants prevent the synthesis of vitamin D Data on anemia prevalence among young children is lacking, but the high prevalence of undernutr-itioni gives a good indication that anemilla is likely to be common among young children. Increases in nutrition-related non-communicable diseases suchi as stomach cancers and coronary heart disease increase the financial burden on the health system and draini resources fi-om basic health care for the poor. While food fortification and supplementation programs are requlred, communication for behavior change programs may be necessary to improve nutritional status in the region Improvements in nutrition require a conscious targeted effort by governments to identify groups at risk and to develop appropriate interventions to address thei- needs. Data on the extent of micronutrient deficiencies are needed to infonn targeted intervention strategies TABLE 4 NUTRITIONAL STATUS INDICATORS Prevalen ce of child mia nutrition Prevalence of Consun.ption Total Underweight Wasting Stulitilig Low birthi anemia of iodized salt Country populationt % of children % of children % oJ children weight % of pregnanit % of (millions) under age S under age S under age 5 % of births womene household.s 1998' 1992-1998' 1992-1998"" 1992-1998 1992-1998" 1985-1999' 1992-1998' Djibouti 06 Yemen 16 9 46 13 39 19 39 Aigeria 30 5 13 9 18 9 42 92 Egypt 66 0 12 5 30 12 24 0 Iran 65 8 16 7 19 10 17 94 Iraq 218 12 9 28 24 18 10 Jordan 63 5 2 16 2 50 95 Lebanoni 3 2 3 3 12 19 49 92 Libya 5 3 5 3 15 5 90 Morocco 27 4 10 2 24 4 45 Syria 15 3 13 9 21 7 40 Tunisia 93 9 4 23 16 38 98 West Bank & Gaza 15 6 14 Bahrain 0 7 7 6 10 6 Kuwait 1 8 2 2 12 6 40 Oman 2 4 23 13 23 8 54 65 Saudi Arabia 20 2 14 3 14 7 United Arab 2 4 7 - 8 -- Emirates 2 4 MENA regional 15 24 10 29 88 av erag e I__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ World Development indicators. 2000/2001 World Bank. Washinigton DC Most recenit data available 4.2. Reproductive Health It is increasingly recognized that improving reproductive health does not only ensure good health outcomes for women and children but also serves as a means for promoting the broader objectives of social and economic development Improving reproductive health is key to achievinig the well being of future generations and prosperity of society as a whole Despite significant improvements in health outcomes in MENA during the past three decades, several reproducti ve health issues remain Compared to other middle-income countries, the MENA region has high fertility rates Although fertility has declined substantially in the region over the past two decades, total fertility rates are high, ranging from 2 2 in Tunis ia to 6.3 in Yemeni, with a regional average of 3 5 births per woman Even lower middle-income countries such as Syria and Jordan have fertility rates of Page 16 FIGURE 2: FERTILITY RATES IN MENA iY- ~ ~ ~ ~ ~ ~~~~~~~~~~~ ,t I usla I -- - x,.._ I.-~ T?7I7 * Lebanon [ I -,_ . . 1 = Iran I I ._. | Ealrain ._ - M oroco^ ,_ _ _ _ _ _ _ . . . . . --- - a Egypt t) i---- .'-------*--UAE 16I Regional r | ._ =>e._L W-.-:--! .t_.J... -.. _ '' , --,'- '-=r' '' -<'-' X * 5'' I Algena tL) -, * - - ;~ - -- ~ t | i . = ...... > . > - _iJordan o ci _ _ _ _ _ _ _ _ _ I~--" ~ _ I I ,r a - Iraq I _ t .I=. --- Oman 4 ,, ~~~~~~~~~~~I _I =_* z ._ 1-E-rs-______ A ab r - 0 1 2 3 4 5 6 7 Total Fertility Rate (Births per woman) FIGURE 3A: MATERNAL DEATHS IN MENA, 1999 UAE 3 Kuwait 5 Saudi Arabia 18 Oman 19 Bahrain 23 Iran 37 Jordan 41 Qatar 41 West Bank Gaza 70 Tunisia 70 Libya 75 Lebanon 100 Syria 110 Egypt 17 Algeria 140 Morocco _ 230 Iraq 4 310 Yemen 350 Djibout 57 0 100 200 300 400 500 600 Maternal Mortality Ratio (Deaths per 100, 000 live births) Page 19 FIGURE 3B: GLOBAL TRENDS IN MATERNAL MORTALITY, 1999 1,600 1,400 - - 1,200 - =g1,000 800- C600 - _ 200 - 20- - =- 10 100 1,000 10,000 100,000 ir/n per capita GNP, US$ FIGURE 3C: GLOBAL TRENDS IN MATERNAL MORTALITY, 1999 1,600- 1,400- = 1,200 - 1,000 - t E 800 - 600- .-8@. ..\ E 600 -__ _ 200-_-. i - 0 10 100 1,000 10,000 100,000 per capita GNP, US$ Note. Data for most recent year available Page 20 4.4. Communicable Diseases Although the disease profile in MENA is changing, infectious diseases remain the leading cause of death and disease burden among young children between the ages of 0 to 4. According to the WHo720 in both low- and high-income countries of the region, diarrheal diseases, perinatal conditions and ALRI were the leading causes of death and burden of disease among young children in 1998 (appendices 7 to 10). Among older age groups, between the ages of 15 to 59 years, tuberculosis was the second leading cause of death in the low and middle -income countries, and the fourth leading cause of morbidity among 15 to 44 year olds in the high-income countries of the region. Acute respiratory infections were responsible for a high burden of disease and were the third leading cause of death among older persons aged 60 years and above in both low - and high- income countries of the region. Hence, communicable diseases continue to be an major cause of morbidity and mortality in both low- and high-income countries of the region. 4.4.1 Vaccine Preventable Diseases According to the World Development Report (1993), vaccine p reventable diseases such as measles, diphtheria, pertussis (or whopping cough) and tetanus account for about 10 percent of the disease burden among children under five, globally. 21 Immunization against these diseases significantly reduces the burden of disease and mortality. Most countries in the MENA region have achieved high rates of immunization coverage (80 to 100 percent) for all vaccine preventable diseases through the implementation of the WHO and UNICEF supported Expanded Program on Immunization (EPI). Yet, Yemen and Iraq have relatively low (60 to 80 percent) immunization rates for BCG, diptheria, polio and measles. Djibouti has the worst situation with less than 40 percent coverage for all immunizations. Coverage for tetanus vaccination is particularly low in almost all countries, ranging from 8 percent in Kuwait to 80 percent in Algeria, with most countries having less than 50 percent coverage. The only country in the region with exceptionally high tetanus vaccination rate is Oman (96 percent ). Immunization rates for hepatitis B are also very high with coverage above 90 percent for all countries except Jordan (83 percent). Apart from Djibouti, Yemen and Iraq, most countries in the MENA region seem to have effective immunization programs. These programs have significantly reduced disease burden and mortality due to vaccine-preventable diseases This observation is supported by the fact that the leading causes of death among young children in the region are perinatal conditions, respiratory i nfections and diarrheal diseases, and not vaccine preventable diseases. The high incidence of perinatal deaths and diarrheal diseases reflects the poor quality of health systems, matemal and child health services, and infectious disease prevention programs existing in these countries. 4.4.2 Acute Respiratory Infections In 1998, ALRI was the leading cause of morbidity among children between the ages of 5 and 14 years in the MENA region. For all age groups combined, ALRI was the second leading cause of death in both low- and high-income countries, and the leading cause of morbidity in the high - income countries of the region (appendices 7 to 10). In the low - and middle-income countries, ALRI was the second leading cause of death followed by diarrheal diseases, and in the high- income countries, ALRI was the leading cause of morbidity for all ages combined. Even among persons aged 60 years and older, respiratory infections were the third leading cause of death after Page 21 ischemic heart disease and cerebrovascular disease. Respiratory infections are, therefore, a major cause of morbidity and mortality among younger and older age groups of both low - and hilgl- income countries of the region. Similarly, ALRI was the second leading cause of death in Southeast Asia, which is mainly a middle-income region (box 3) 20 In fact, ALRI was the leading cause of morbidity as measured by Disability Adjusted Life Years (DALYs), and the second leading causes of death globally in 1998 20 Efforts to reduce ALRI require improvements in health services delivery and technical competence/capability of health personnel to effectively manage (diagnose and treat) ALRI at the health facility level. Education of caretakers at the household level to recognize symptoms and seek timely care is also necessary to reduce the severity of ALRI morbidity and prevent mortality Equipping primary health care facilities with algorithms or practice guidelines and the necessary resources for ALRI case management should be an appropriate strategy to reduce disease burden and mortality due to ALRI 4.4.3 HIV/AIDS Because of insufficient data, HIV infection rates for the MENA region are often estimated As of the end of 1999, an estimated 220,000 adults and children were living with HIV/AIDS in the MENA region giving an infection rate of 0.13 percent (appendix 6). The HIV prevalence rate is highest in Djibouti, and appears to be increasing steadily in Iran, Lebanoni, Kuwait, Omani, Saudi Arabia, Bahrain and UAE. In some countries, a large proportion of cases have been reported among expatriates. Most HIV infection in the region is transmitted through heterosexual contact In Iran, however, a high proportion of infections are contracted through intravenous drug use, an emerging issue of public health concern in the region. Compared to data from neiglhborinig Asia, Europe and Sub-Saharan Africa, it would seem that HIV infection rates in the MENA regionl are relatively low (box 3). Recent evidence, however, suggests that the incidence of sexually transmitted infections (STIs) including HIV/AIDS is increasing, and the total number of AIDS deaths has increased almost six fold since the early 1990s. For example, localized stLdies in southern Algeria showing rates of around I percent in pregnant womilenI attendinig antenatal clinics indicate that HIV is spreading rapidly among the general population. With an estimated 80,000 new infections occurring in the region in the year 2000 alone, the number of adults and children living with H1V/AIDS reached 400,000 by end-2000.22 The number of deaths due to HIV increased from 13,000 in 1999 to 24,000 at the end of 2000, and adult HIV prevalence rate has almost doubled to 0 2 percent (40% women) in the same period In 2001, approximately 80,000 persons in the region were newly infected with HIV in the MENA region. The situation in Djibouti is particularly troubling with about 12 percent of the adult population living with HIV/AIDS, the highest in the region. In the low- and middle-income countries of the region, HIV/AIDS was the third leading cause of morbidity among 14 to 44 year olds in 1998 (appendix 18) Although the current rate of HIV infection in MENA is low compared to other regions, early intervention to curb the spread of HIV/AIDS is vital, because once the prevalence of the infection exceeds a certain threshold, HIV spreads very quickly, it can increase tenfold in five years as it has in several southern African countries. The more widely HIV/AIDS spreads, the more difficult and costly prevention and treatment become. In Sub-Saharan Africa, it is estimated that a national HIV/AIDS prevention program would cost less than US$3 per capita wh ile prevalence remained below 5 percent Once rates reach 15 percent, however, program costs could be US$12 per capita. The longer the introduction of programs is delayed, the greater the likelihood that the epidemic will grow exponentially. Countries, therefore, have two policy options: (a) delay action while HIV Page 22 prevalence is low and have far higher expenses to control it once it spreads; or (b) take comprehensive action now to prevent HIV infection before it becomes a serious issue. Early and aggressive intervention against the epidemic has paid dividends in several places such as Uganda, Senegal., Thailand and Tamil Nadu in India Prevention not only averts suffering and death, but pays vast dividends in future savings to the health system and the public sector at large. Cost effective interventions such as greater use of condoms, public information programs, and treatment of sexually transmitted infections cost as little as US$8 per infection averted, compared to the hundreds of dollars that each case of AIDS costs to treat.23 Despite a lack of vaccine, behavior change has been proven to be a highly effective means of reducing HIV transmission. Young people are especially receptive to leaming safe behavior messages and skills. For many individuals and couples, finding out about their infection status could help trigger behavior change. One approach is to make voluntary testing services more convenient to clients. One major concem about HIV/AIDS in the region, however, is the scant information about HIV prevalence rates and the reliability of the data. Given the global trend in the HIV/AIDS epidemic, it is necessary to establish surveillance systems to obtain up -to-date accurate data on the extent of the problem in the region, monitor trends and identify socioeconomic and cultural factors which may be contnbuting to it's spread for appropriate action. HIV/AIDS programs should be multisectoral, and the costs could be spread among several ministries, agencies, civil society, and private actors. 4.4.4 Tuberculosis Tuberculosis is a significant public health problem in many countries of the Middle East and North Africa region, especially among lower middle -income and poor countries. Djibouti has the highest TB infection rates in the region (596.7 per 100,000 population), followed by Iraq (139 1), Morocco (106.2) and Yemen (73.3 per 100,000 population) All other countries in the region have less than 20 cases per 100,000 population. According to WHO, tuberculosis was the second leading cause of death and the third leading cause of morbidity among the economically productive age group (15-59 years) of the low- and middle-income countries of the Eastern Mediterranean region in 1998 (appendices 9 and 10). With increasing HIV infections in the region, the incidence of TB is likely to increase even more significantly. Following a 1991 World Health Assembly resolution,24 WHO urged National Tuberculosis Control programs to work towards two objectives by the year 2000- (a) to treat successfully 85 percent of detected smear positive cases; and (b) to detect 70 percent of all such cases by the introduction of an effective approach to TB control through the WHO Directly Observed Therapy Short course (DOTS).25 DOTS has been adopted as policy by over 115 countries worldwide, but as of 1999, it has reached less than 25 percent of infectious TB cases worldwide. Apart from Bahrain, Kuwait, Saudi Arabia, UAE, Lebanon, Tunisia and the West Bank and Gaza, all other countries in the region had adopted the DOTS strategy for TB control by 1998. Djibouti and Morocco both have high TB prevalence rates and high case detection rates of 79.4 and 87.6 percent respectively Detection of new cases in Yemen and Iraq are relatively low (58 and 56.4 percent respectively). Detection of new smear positive cases in the region was 26.5 percent, which is far below the global target of 70 percent set by the WHO to be achieved by 2005. As of 1997, Iran, Oman and Syria had achieved treatment success rates of 85 percent and above, while Egy pt, Morocco and Yemen had rates of 81 to 83 percent, which was close to the WHO target of 85 percent. The tuberculosis treatment success rate achieved in the region was 77.1 percent. Page 23 The key to mecting WHO targets lies in expanding case detection in hig h TB burdell, DOTS implementing countries. Most countries will have to introducc innovative methods to find and treat cases that are not yet notified A number of actions at the regional, national and local levels need to occur in order to rapidly expand access to DOTS and ensure good quality diagnosis and treatment in the context of a worsening epidemic. Evidence from national TB programs and local pilot experiences suggest that explicit enablers and/or inceitives to motivate both health workers and patients may bc essential to scaling up and sustaining DOTS withinl primiary health carc 4.4.5 Malaria Malaria does not appear to be a major cause of death in MENA, but is a significant cause of death among young children (0 to 14 years) in the low- and middle-income countries of the region In 1998, malaria was responsible for about 46,532 deaths among this age group (appendix 17). A high proportion of malaria cases occurring in the MENA region are found mainly in Yemell and Djibouti Conditions for malaria transmission are most favorable in the areas encompassing the Arabian Peninsula, and P Jalciprlm in this part of the region exists only along the eastern border of Iran and in one focal area in Egypt. Most of the malaria cases in Iran are imported from neighboring countries, including Afghanistan, Pakistan, Iraq, Armenia and Azerbaijan, helice impoi-tation from abroad is an issue Of particular concern is the importation of chloroqulie - resistant P falciparinm, which is the main reason for the transmission of in alaria in southeastern Iran. In the rest of the region, malaria is no longer an issue or has become sporadic Unfortunately, the gradual disappearance of malar-ia has been interrupted in those countries that have suffered from war and political instability Countries in the region can be grouped as follows. * Countries where malaria transmission does not occur, or sporadically occurs, after importation: Bahrain, Jordan, Kuwait, Lcbanon, Libya, Qatar and Tunisia, * Countries with effective malaria control programs where malaria is quite well contained, and eradication of malaria is feasible and sustainable. Egypt, Morocco, Omall, and UAE Iran, Saudi Arabia and Syria also have effective malaria control programs that could reduce morbidity, and * Countries with a serious malaria problem: Djibouti and Yemen, both withi poor health systems; and Iraq which is outside the area of afro -tropical malaria but with a damaged health system. The most important technical issues in countries with continuing malaria transmii ssioi are (a) the development of mechanisms for predicting, detecting and controlling malaria epidemics, (b) the development of a system of continuous monitoring of therapeutic efficacy of drugs, and (c) the reorientation of malaria surveillance and information systems towards monitorinig the incidenice of severe cases and mortality due to malaria In countries where interruption of transmission is feasible and likely to be sustainable, as well as in countr-ies that have achieved an interription of transmission, updating the strategy for prevention of reintroduction of malaria is needed. Djibouti, Yemen and Iraq have the most serious malaria problem, and all three have poor health systems and poor social infrastructure. These countries and most of the remain ing countries require strengthening of the core of the malaria control program and improvement in the presentation of malaria control in primary health care activities. There is a need for improving partnership and developing effective intersectoral collaboration for malaria control. Page 24 4.5.1. Cardiovascular Diseases Cardiovascular diseases (CVDs) have long been the leading cause of death and disability in developed countries, and currently account for about 20 percent of all deaths globally. In low - income countries, CVDs are emerging as significant causes of death and disability, and are already the leading cause of death in many countries with economie s in transition. The rise in CVDsis a result of improvements in socioeconomic development that are often associated with changing lifestyles, such as smoking and lack of activity, and are risk factors for chronic diseases, and CVDs in particular. Also, as the population ages with declining fertility, the proportion of deaths and morbidity due to chronic diseases increases. In the MENA region, CVDs are increasingly becoming the leading cause of morbidity and mortality as countnes go through the demographic and epidemiological transitions. In Jordan, for example, a national survey in 1995 showed that CVDs were the leading cause of death, accounting for 42 percent of all deaths at the time. 27 In 1998, CVDs (ischemic heart disease and cerebrovascular diseas e) were the leading cause of death in both high- and low-income countries of MENA.20 In the high-icome countres of the region, CVDs contributed to three times as many deaths (7,424 deaths) as did the second leading cause of death - acute lower respiratory infections (2,818 deaths).20 In the low- and middle-income countries of the region, however, the burden of diseases due to CVDs was lower, with ischemic heart disease placing fifth as the leading cause of morbidity, after permatal conditions, acute lower respiratory infections, diarrheal diseases and injuries. Among persons aged 45 years and above however, CVDs were responsible for the highest burden of disease s in the low- and middle-income countries of the region in 1998. Not only is CVD the largest cause of mortality in older age groups, it is also a very significant contributor to mortality in persons of economically productive ages (i.e., 15 to 59 years). This burden of disease and death in the economically most productive age stratum has important consequences for health care resources and for the economy in general. In high-income countries of the region, stroke is the third most common cause of death a nd the leading cause of disability among the elderly Because populations in MENA have traditionally been younger, stroke, which tends to affect mainly the elderly, has not been a major problem in the region. However, as populations in these countries grow older it is anticipated that stroke will become a larger contributor to morbidity and mortality. Major risk factors for stroke identified are age and hypertension. In low-income countries, infectious diseases such as tuberculosis, syphilis, and parasitic diseases (e.g., schistosomiasis) are common causes of cardiovascular disease. Other than the prevention and treatment of these infectious agents, the principles for preventing CVDs in low-income and high-income countries are similar. Mild elevations in blood pressure can be ameliorated by reducing salt intake, limiting alcohol consumption and engaging in physical activity. Higher elevations generally require medical therapy. 4.5.2. Cancer Cancers are usually classified according to the organ where the abn ormal cellular growth begins, as well as by the specific type of tissue that becomes malignant within the organ. Major differences in the relative importance of specific cancers currently exist between high - and low-income countries of the MENA region. In the high-income countries, cancers of the lung, breast, colon and prostate are the most frequent types, and in the low -income countries malignancies are most common in the mouth and oropharynx, stomach, and liver. For example, breast cancer is the most common type of cancer among women in Jordan, accounting for 25 percent of all cancer cases. It Page 27 is also the leading cause of cancer death in women.""' Although lung cancer is relatively less commoni in low-income countries, it is a growing source of morbidity and mortality as tobacco smoking becomes more prevalent 28 In general, heavy use of alcohol and tobacco (smoked and chewed) are the major risk factors for tumors of the lip, tongue, oral cavity, nose, and pharynix However, in MENA countries, alcohol consumption is still relatively minimal and is not considered as an aetiologic agent for cancer Infectious agents such as hepatitis B and C are also important etiological agents for liver cancer, and so are parasites such as schistosomes and liver flukes 29 Shistosomiasis in particular is common in Egypt where people bathe and drink water infested with schistosomes. An importanit Issue associated with cancer control in low- and middle-incomne countries is that medical treatment with surgery or chemotherapeutic medicines are neither widely available nor affordable Therefore, it is necessary to concentrate on prevention rather than treatment Even in high-income countries such as the United States, where enormous resources are devoted to treating cancer, prevention efforts have proven the most successful means to decrease mortality from this disease. The maintenance of a reliable cancer registration system is technically complex and expensive, thus, infornation on the incidence of cancers in the region is sp arse. However, it is necessary to begin to invest in a regional non-communicable disease database to provide a knowledge base for informing regional public health strategies. Box 4: NON-COMMUNICABLE DISEASES * Globally * CVDs (Ischernic heart disease and cerebrovascular disease) were the leading causes of death in all regions of the world except Africa and the Western pacific in 1998 * In both high and low-income countries of MENA * CVDs were the leading cause of death in 1998 * In the low and middle-income countries of the region: * CVDs were responsible for the highest burden of diseases among persons aged 45 years and above * In the high-income countries of MENA. * CVDs contributed to three times as many deaths (7,424 deaths) as acute lower respiratory infections (2,818 deaths), * Stroke was the third most common cause of death and the leading cause of disability amolig the elderly, * Cancers of the lung, breast, colon and prostate occurred more frequently, while malignancies in the mouth and oropharynx, stomach, and liver were more common in the low-income countries, and * Diabetes was the fifth leading cause of death among persons aged over 45 years "" Data obiained from the Jordan National Cancer Registry, 1997, Presented in a pi oject proposal submiitted to the World Bank by Her Royal Highncss Princess Aisha Bint Al Hussein Page 28 4.5.3. Tobacco-related Diseases The impact of tobacco on health has been well documented. Evidence from numerous studies show that smoking is associated with lung cancer, and cancers of various other organs, including the bladder, kidney, larynx, mouth, pancreas and stomach. Smoking is also associated with vascular diseases including heart attacks, strokes and other dtseases of the arteries or veins It is also the leading cause of chronic bronchitis and emphysema. Conventionally, countries with high rates of smoking prevalence have corresponding high rates of trachea, lung and bronchus cancer (figure 4). Lebanon, Syria and Yemen exemplify this pattern with high rates of smoking and mortality due to lung, trachea and bronchus cancer Tunisia, with a high smoking prevalence, has a high incidence of lung cancer as well as lip, oral and pharynx cancer. Although smoking prevalence is highest in Djibouti (75 percent), surprisingly, mortality due to cancer of the lung, trachea and bronchus are not as high (14.6 per 100,000 population), unlike mortality due to cancers of the lip, oral and pharynx, which are very high (24.8 per 1,000 population). Tobacco is currently responsible for one in ten adult deaths worldwide; by 2030 the figure is expected to be one in six - or 10 million deaths each year - more than any other cause and more than the projected death tolls from pneumonia, diarrheal diseases, tuberculosis, and the complications of childbirth combined. If current trends persist, about 500 million people alive today will eventually be killed by tobacco, half of them in productive middle age, losing 20 to 25 years of life. In fact, it is estimated that 20 percent of all cancer deaths could be prevented by eliminating tobacco smoking alone.3' Smoking related deaths previously confined to men in high- income countries, are now spreading to women in high-income countries and men and women in middle- and low-income countries throughout the world. Whereas in 1990, two out of every three smoking-related deaths were in high-income countries, by 2030, seven out of every ten deaths will be in low- and middle-income countries.32 It is also estimated that by 2020, 12 percent of tobacco-related deaths will be in the MENA region. Tobacco Use Levels of tobacco consumption have been found to increas e with rising levels of national income in developing countries.33 As a result of the great variation in levels of economic development and social norms in the MENA region, the extent of tobacco use, disease burden and tobacco control activities vary tremendously. The countries can be divided into two groups according to trends in per capita cigarette consumption between 1970 and 1998 The first group of countries, which include Iran, Iraq, Jordan, and Saudi Arabia, show steady levels of per capita consum ption, with only minor vanations among years. The second group of countries shows either a marked rise or decline in per capita cigarette consumption at various points in time, though the trend was not sustained. Countries generally showing increased per capita cigarette consumption include Egypt and Syria, and showing decreased consumption is Kuwait. Apparent increases in cigarette consumption have been associated with times of national crises and spread of western media (i.e., television, cinema and magazines) through the region The observed patterns of cigarette smoking in the MENA region are very mixed. The adult male smoking prevalence is very high in many countries. On average, 44 percent of men smoke in the region compared to 61 percent in East Asia and Pacific, 57 percent in Europe and Central Asia, 40 percent in Latin Amenca and the Caribbean, and 29 percent in Sub -Saharan Africa (appendix 9). Smoking among adult men is highest in Djibouti (75 percent), followed closely by Tunisia (61 percent), and Yemen (60 percent) (appendix 8). Oman has the lowest smoking prevalence rate among men. Page 29 In general, cigarette smoking among women in the region is less common than in other regions Five percent of women in MENA smoke Yemen has the highest smoking prevalence among women (29 percent). Even then, the male to female ratio of smokers remamis 2 1, and is even higher in Arabian Gulf countries such as the UAE (24 1), Bahrain (22:1), Oman (16 1), and Kuwait ( 12 1 ) Apart from Yemen, female smoking rates in these countries are very low. There is less data on the prevalence of smoking among youth in the region. However, The Global Youth Tobacco Survey conducted by the WHO in 1999 reported high rates of tobacco use among Jordanian youth. Surprisinigly, over 97 percent of youth in Jordan use some form of tobacco Smoking experience appears to start early with over 30 percent of youth surveyed, both male and female, reportedly trying a cigarette before age 10. Although smoking patterns vary in the region, these high smoking prevalence rates among Jordanian youth are disturbing and point to a looming epidemic of smoking-related diseases in Jordan and the rest of the region. Another disturbing trend is the increasing smoking rates among the youth, particularly young women In countries with large populations, the possibility of a sharp rise in smoking rates amolig females and youth represents a major public health concern. A person's risk of developing smoking -related disease, for example lung cancer, is determined more strongly by the duration of smoking than by the number of cigarettes smoked daily Therefore, early smoking initiation is associated with a higher risk of tobacco-related diseases, which emphasizes the need to target the youth in smok iig cessation programs. Given the strong econoiriic importance of the tobacco industry in the region, cigarette use will probably remain a strong behavioral risk factor for health in the future. With a regional smoking prevalence rate of 44 percent (appen dix 8), Lopez and colleagues34 suggest that countries in the MENA region are in stage two of the tobacco epidemic This stage is characterized by increases in smoking prevalence to about 50 percent; an early increase in smoking prevalence among women; and rising death rates from lung cancer among men In such countries, tobacco control activities are usually not well developed, the health risks of tobacco not widely understood, and there is relatively low public and political support for the implementation of effective tobacco control measures. Here, as in stage one of the epidemic, regional and international collaboration is essential to accelerate the development of effective tobacco control. Tobacco Control A number of efforts to control tobacco in the MENA region have been successful These are. * Wider dissemination of infonration about the hazards of smoking, including health warnings on cigarette packets; * Increasimg taxes on tobacco products that limit to some degree tobacco consumilption and generating revenue for tobacco control; and * Reducing the tar and nicotine levels in cigarettes sold in the Gulf States. Most countries in the region have issued regulations to restrict or ban cigarette smoking in closed public areas such as workplaces, schools, healthcare facilities, government buildings, aboard aircraft, and on public transportation. Provisions to reduce the amount of nicotine and tar in cigarettes are less common, and where there are allowable restrictions, the maximum allowable level varies among countries, ranging from 0 6 mg to I mg for nicotine, and 10 to 15 mg for tar The tightest standards for tar and nicotine exist in the UAE, where 0.6 mg nicotile and 10 nig tar have established the upper limits since 1989. The minimum age to purchas e cigarettes also varies among countries. In countries with prohibitions against tobacco sale to minors, 18 years is usually the minimum for purchasing tobacco. Kuwait, however, permits sales only to individuals older than 2 1 years Page 30 Challenges The challenges to reducing tobacco use among MENA countries are that the health consequences of tobacco are often not immediate, and it is easy to remain unconcerned or even complacent. Detailed annual statistics on causes of deaths are not available in most MENA countries, and there are often no country specific estimates of smoking-attributable mortality. Tobacco products are a tremendous source of revenue for businesses at the level of production and distribution. These products are also a major source of tax revenue for many govemments, thus presenting a major disincentive for governments to control the habit Tobacco control, while recognized as important to the future health of the region, struggles to gain the necessary resources and commitment in the face of competing priorities, and in all countries of the region, disease prevention traditionally is given lower priority than treatment. These challenges must be overcome in order to prevent the looming epidemic of costly-to-treat non-communicable diseases associated with tobacco use, which are preventable with effective public health interventions. Even if there were to be a major decline in smoking rates, given the lag time between the behavior and health outcomes, the effect on chronic diseases will not be seen for several decades. Thus, there is every reason to predict that smoking-related diseases will continue to be of major significance in MENA for a while. FIGURE 4: SMOKING PREVALENCE AND CANCER (LUNG, TRACHEA AND BRONCHUS) 80 120 70 100 _ ~~~~~~~~~~~~~~~~~~ o1 .2 60 50- ~ ~ E 80CX 50 0 -\.-Smoking Prevalence 0 40 60 . 0. E 30 40 0 o - -Trachea & lung Cancer 020 1- 0 E 20 10_ m0 0- ~~~~~~~0~ 0 ~ ~ ~ ' Countries Page 31 4.5.4. Other Chronic Diseases Data on chronic diseases in the MENA region are lacking. However, in terms of mortality and morbidity, the most important chronic diseases are illnesses of the cardiovascular system and cancer. Nonetlheless, there are many other chronic diseases of great importance For example, diabetes, while an enonnously prevalent and strong risk factor for cardiovascular diseases, is a major source of disability throughout the region. Diabetes is already a major health problem in MENA and the fifth leading cause of death among persons aged over 45 years in the high- income countries of the region (appendix 17). A 1996 morbidity survey in Jordan showed that a high proportion (17 percent) of the adult population aged 25 years and above were diabetic. 27 In Saudi Arabia, diabetes incidence in the adult population is currently estimated at about 45 per 1,000 population and is expected to increase to about 58 by 2025. 35 Several other chronic conditions such as chronic obstnictive pulmonary disease, inusculoskeletal conditions such as osteoporosis, osteoarthritis and rheumatoid arthritis are major sources of disability and suffering, particularly for the elderly. Neuro-psychiatric conditions such as depression and dementia, and other mental conditions are also growing sources of morbidity and iriortality in the region Currently unipolar major depression places fifth and sixth as the leading cause of morbidity in the high- and mi lddle-income countries of the region respecti vely, after perinatal conditions, respiratory infections, diarrheal diseases, war injuries and ischemic heart disease By 2020, mental disorders are expected to account for the second largest Disability Adjusted Life Years (DALY) loss for n1on1 - communicable diseases in the MF.NA region. As the population of MENA ages, these conditions will become even more common in the region. Prevention and treatment of underlying causes of thcse conditions present major opportunities to Improve the health of populatiolns in MENA. 4.5.5. Nutrition and Physical Activity Although eating behaviors aiid physical activity are considered important behavioral risk factors in the etiology of chronic diseases, data available on them in the MENA region are very scant Data from the Jordanian morbidity survey in 1996 indicates that 68 percent of the adult population were obese (BMI >25 kg/in2), and 25 percent self-reportedly engaged in no physical activity 27 Unfortunately, physical activity is very difficult to measure universally The interrelationslhips among these two risk factors and chronic diseases are complex. For example, obesity is a diet - related chronic disease condition by itself However, it is also widely recognized as a key ris k factor for heart diseases and diabetes, and is also highly influenced by levels of physical activity. Just like eating behavior, it is tied to many other factors such as income, work, transportationi, leisure and drinking behavior. The prevalence of obe sity increases along with associated problems of hypertension, non-insulin dependent diabetes and inusculoskeletal disorders when high-energy diets that are high in saturated fats from animal sources are combined with the sedentary lifestyle frequently cultivated with economic development. Countries in the midst of rapid economlic development such as in MENA are particularly vulnerable to the ravages of such diets, which can result in increased rates of diabetes, cardiovascular disease, and hypertension. Mo tilting the interventions necessary to forestall such dietary practices in all countries of the region is a profound challenge to public health in MENA. 4.5.6. Alcohol Use Alcohol use is a major contributor to chronic disease and injuries. Serious alcohol abus e appears to be a minor problem in MENA countries, but the trend appears to be changing. In some countries of the region alcohol is used as a daily or regular beverage. At the same thne, many countries prohibit or restrict alcohol tise. Drinking patterns vary greatly by country and withlin countries. Page 32 Some of the factors that define these patterns in countries are religion, ethnicity, race, gender, and socioeconomic status. The majority of the female population does not drink alcohol and nearly half of males abstain. Alcohol influences many, if not all injury types. For motor vehicle injuries, there appears to be a dose-response relationship, with high blood alcohol levels leading to more severe injuries. Alcohol also contributes to other injuries such a s drowning, fires, falls, pedestrian and occupational injuries The morbidity and mortality attributable to alcohol use is difficult to ascertain. Hence, such data is not available. 4.6. Injuries Injuries are typically classified according to whether they are intentional or unintentional. Intentional injuries, or violence, include those that result from war, homicide, suicide, interpersonal and collective violence and self-harm. Unintentional injuries are those previously considered "accidents" and include poisoning, fires, burns and scalds, drowning, suffocation, falls, sports injuries, and motor vehicle and transportation -related injuries. Worldwide, in 1998 alone, injuries were responsible for an estimated 5.8 million deaths. Ranking fifth among the leading causes of death, unintentional injuries accounted for 5.2 percent of 26 the total mortality, and were responsible for 10 to 30 percent of all hospital admissions. The majority of unintentional injuries in the world occur in low-income countries. Specifically, low- income nations are responsible for more than 70 percent of the world's motor vehicle injuries. From a regional perspective, injuries appear to cause the greatest mortality in areas where war and civil violence are prevalent, as in several countries of MENA engaged in prolonged civil and international conflicts and violence. The burden of injury is particularly evident in countries where communicable and infectious diseases have been substantially controlled. As infectious diseases diminish, injuries increase in significance as a major health threat. Motor vehicle accidents are the leading cause of injury mortality worldwide. In the low - and middle-income countries of the MENA region, war and road traffic injuries were the second and third leading causes of morbidity and mortality among 5 to 14 year olds in 1998 (appendices 9 and 10) Among the economically productive age group (15 to 44 year olds), war injuries were the leading cause of morbidity and mortality, and road traffic injuries were the third leading cause of death In the high-income countries of the region, war injuries were the leading cause of death among 15 to 44 year olds, followed by road traffic injuries. Even among 5 to 14 year olds, war injuries, self inflicted injuries and road traffic injuries were the second, third and fourth leading causes of morbidity and mortality, respectively. According to a recent study, 20 percent of beds in MOH hospitals in Saudi Arabia are occupied by traffic accidents victims alone.36 A clear indication that road traffic injuries are a major public health problem in the country, and the rest of the region. In low-income countries where fewer resources are spent on prevention, road traffi c accidents have become a major source of disability and premature death. A number of factors contributing to the motor vehicle injury problem in low income countries include rapid population growth, increasing motorization, lack of safety features in cars, poor road maintenance, lack of police enforcement, and poor access to emergency care. Alcohol influences many, if not all injury types. For motor vehicle injuries, there appears to be a dose -response relationship with high blood alcohol levels leading to more severe injuries. Whereas greater concentrations of automobiles increase vehicle crashes in urban areas, mortality in rural areas tends to be higher with poorer road conditions and poorer access to medical care, leading to higher injury rates and p oorer outcomes in rural areas. Page 33 Effective injury control interventions need to target the main determinants of injury, whIchC are behaviors, products, and the environment Three strategies for injury prevention and control are (a) education and behavior change modification strategies, (b) legislation and enforcement strategies to modify environments; and (c) technology and engineering strategies to modify products Used together, these strategies can complement one another in efforts to prevent and control injuries 26 Box 5: INJURIES 4 In the low and middle-income countries of MENA . War was the second leading cause of morbidity and mortality among 5 to 14 year olds in 1998, . Road traffic injuries were the third Ieading causes of morbidity and mortality among 5 to 14 year olds in 1998, and . Among the economilcally productive age group (15 to 44 year olds), wai injuries were the leading cause of morbidity and mortality, and road traffic injuries were the third leading cause of death * In the high-income countries * War injuries were the leading cause of death among 15 to 44 year olds, followed by road traffic injuries, and * Among 5 to 14 year olds, war injuries, self inflicted injuries and road traffic injuries were the second, third and fourth leading causes of morbidity and mortality, respectively 4.7. Demographic and Epidemiological Transitions Countries in the MENA region are experiencing changes in their demographic and epidemiological profiles as well as in their overall social environments These changes are prompted by the demographic and epiderniological transitions, which are characterized by: (a) reductions in fertility and mortality; (b) reduction in the incidence of communicable diseases with simultaneous increases in chronic diseases and injuries; and (c) improvements in socioeconomiiic development accompanied by rapid urbanization and changing lifestyles. Over the next three decades, health patterns in the region will be profoundly influenced by continued declines in fertility and mortality as the countries go through the demographic transition. A fifty percent decline in fertility with modest gains in life expectancy is projected for the region. 3 The overall effect of the declines in fertility and mortality is a dramatic shift in the age structure and causes of morbidity and mortality. The proportion of non-communicable diseases and injuries is likely to increase significantly throughout the region as a result of aging. Presently, countries in the region are at substantially different stages l of the demographic transition (figure 5) Yemen and Djibouti, for example, are both in the early (second) stage of the transition ' The demographic transition model describes changes in human fertility and mortality related to shifts in economic development, brought about by industrialization and urbanization It comprises of four stagcs Stage I high birth and death rates, Stage 2 declining death rates and continuing high birth rates, Stage 3 declining birth and death rates, and Stage 4 low birth and death rates Page 34 with relatively high rates of fertility (>30 births per 1,000 population) and mortality (>10 deaths per 1,000 population), and demographic profiles comparable to the least developed countries of the world. Iraq, unlike Yemen or Djibouti, is relatively wealthier, but has high fertility and mortality levels due to deteriorating health and socioeconomic conditions as a result of economic sanctions imposed on it by the intemnational community since 1991. The middle-income countries of Algeria, Egypt, Iran, Jordan, Lebanon, Morocco and Tunisia have declining fertility (17 to 30 births per 1,000) and mortality rates (5 to 10 deaths per 1,000), and appear to be in the third stage of the transition Typically, most middle-income countries tend to be at the third stage of the demographic transition (mid-transition). Upper middle-income countries such as Saudi Arabia and Oman appear to be at the third stage of the transition with very high birth rates (>28 births per 1,000) and low mortality rates (<5 deaths per 1,000) that are comparable to the new industrial countries of East Asia, such as Indonesia and Malaysia. The remaining upper middle -income countries of the region (Kuwait and UAE) have low fertility and mortality rates and seem to have initiated the fourth phase of the demographic transition. The transformation in the cause of death and age structure associated with the demographic transition has been termed the "epidemiological transition" 38 Three distinct factors characterize an epidemiological transition, each of which has implications for public health. The first is th e decline in fertility, which leads, as discussed previously, to an older age structure. Second is a decline in mortality due to infectious and parasitic diseases as a result of improvements in health care and public health interventions, resulting in increased mortality due to chronic and degenerative conditions Third, changes can occur in morbidity and mortality rates from non -infectious conditions that can substantially alter the risks of death among adults and the aged Injuries are also likely to increase with the epidemiological transition. Currently, the proportion of disease burden due to non -communicable diseases in MENA is expected to increase from 45 percent in 2000 to 60 percent by 2020, while the burden of injuries increases from 15 percent in 2000 to 20 percent in 2020X 39. The proportion of disease burden due to communicable diseases has declined from 48 percent in 1990 to 29 percent in 2000, and is expected to decline further to 20 percent by the year 2020 (figure 7). The rapid urbanization, industrialization, mechanization of agriculture and introduction of toxic wastes by countries in the region is also likely to result in unprecedented high levels of accidents and injuries. Current epidemiological trends are also influenced by the emergence and re-emergence of health problems such as HIV/AIDS, tuberculosis and malaria. These trends have important implications for public health policy, programs and health services delivery in the region. Most of the lower middle-income countries are presently undergoing a penod of "protracted polarized" epidemiological transition. This is charactenzed by an overall decline in mortality rates but with persistent high incidence of infectious diseases among certain groups, usually the rural poor, and a concurrent rise in the proportion of disease burden attributable to non -communicable diseases. In the low- and middle-income countnes of the region, although ischemic heart disease was the leading cause of death for all ages in 1998, infectious diseases (i.e., diarrhea and ALRI) were the second and third leading causes of death responsible for a higher number of deaths in the region. In the high-income countries of the region, while non-communicable diseases are the major cause of death, infectious diseases continue to be responsible for a significant disease burden for all ages. This situation presents a clear indication of the epidemiological polarization. One consequence of the epidemiological polarization is its widening effect on the dispanties between the urban and rural population, and between the wealthy and the poor. The treatment of non -communicable diseases is x Estimates of disease burden and mortality are projections based on the global burden of disease study conducted by Murray and Lopez in 1990 and further refined using an extensive data base of morbidity and mortality from the various sub-regions ofthe world and more robust modeling techniques Page 35 relatively costly and technology-intensive Consequently, an increasing share of resources is channeled toward the treatment of these cases, which usually beilefits the urban population and leaves a smaller share of resources for the rural poor. Finding a balance between the competing demands on rcsources presents a major challenge for these middle -income countries. FIGURE 5. THE DEMOGRAPHIC TRANSITION The Demographic Transition Rates per 11000 Stage _._1 Stg tg tg 30 Xpulation irth Rate 0 ~20 410 0 |~~~~~~~- b 0~~~~~~~~~~ ';0 10- \ f ?~~~0 ra 0 0,Z g (tr ,a '( jZ (D ,o- 44/ Countdes Page 36 FIGURE 7: CHANGING DISEASE BURDEN- MENA 70 - ~60- y 50 ' u =+-- Comrnunicable U--Noni-Communicable a) .tn 30 - - Injurnes 0 ~20- 1 10 0 1990 2000 2010 2020 Year Data Source World Bank Estimates, Human Development Network Data World Bank, 2000 FIGURE 8: TRENDS IN DEATHS BY CAUSE IN THE MIDDLE EASTERN CRESCENT 80 70- 60- -5 50 -4- Communicable 40 -Non-communicable -i-Injuries 30 - 20 - 10 0 , I 1990 2000 2010 2020 Year Data Source World Bank Estimates, Human Development Network Data World Bank, 2000 Page 3 7 5. Public Health Activities 5.1.Government Activities The changing burden of illness from communnicable diseases toward expensive-to-treat non- communicable diseases and InJuries has Important implications for public health strategies, health system configurations, and health spending in the region. Although many government hcalth policies emphasize the control of communicable diseases and primary health care and provide such services, many countries in the region have initiated reforms of their health sector in recent years to cope with changing demands of the health care system The health sector r eforms are targeted at improving access to health care, equity, economic efficicncy, quality, consumer satisfaction and future financial sustainability, which are necessary concomilitanits for successful economic and social development 40 However, they do not adequately address the issue of the increasing burden of non-communicable disease, injuries and emerging diseases, which can only be reduced with appropriate public health interventions. The Ministr-ies of Health in most countries of the MENA regioni have been mainly cngaged in public health activities focusing on communicable diseases and matemal and child hcalthi Regarding non-comIInMinicable diseases and related risk factors, most countries have issued regulations to restrict or ban cigarette smoking in c losed public areas such as workplaces, schools, healthcare facilities, government buildings, aboard aircraft, and on public transportation. Provisions to reduce the amount of nicotine and tar in cigarettes are less common, and where there arc allowable restrictions, the maximum allowable level varies among countries, ranging from 0 6 mg to I mg for nicotine, and 10 to 15 mg for tar Efforts at strengthening the public health infrastructure have been insufficient to date There are efforts to imiprove girls' education in some countries of the region Iran is promotinig education for women and girls in rural areas, with girls' primary school attendance now over 90 percent Programs in Egypt, Morocco, Tunisia and Yemen are bringing education to girls in poor areas through community schools located closer to their homes In Egypt, for example, comlmlunlity schools have been implemented through strong partnerships among the Ministry of Education, Communities, NGOs and UNICEF, based on the principle of community o wnership These schools, which target girls in deprived rural hamlets, employ a model of active learning, which fosters creativity, critical thinking and problem solving skills as the basis for lifelong lcarning 5.2.Activities of Other Organizations Various NGOs and other pnvate groups also provide health services in the region For example, i n the West Bank and Gaza, parallel networks were operated for 30 years by the Israell Civil Administration, Palestinian NGOs and United Nations Relief and Works Age ncy (UNRWA) to provide healthcare for Palestine Refugees The Roll Back Malaria (RBM) program, a global partnership formed by the WHO, UNICEF, UNDP and the World Bank to reduce the global burden of malaria, aims at, among other things, strengthening health systems to ensure adequate access to care by those suffering from malaria. RBM activities in the region started in November 1998. The main elements of the RBM strategy include early detection and rapid treatment of cases, multiple and sustainable prevention strategies, focused research and well -coordinated interventions thl-ough dynamic global movement and partnership It also promotes the development of effective health systems, which are needed to contain malaria. The WHO also has an injury preventio n program that assists member countries in building capacity and locating support for injury control activities Page 38 The WHO is also very much involved in tobacco control activities in the region. A joint WHO/World Bank conference to address the issue of tobacco control took place in Malta in September 2001. In general, NGOs have been actively involved in the public health activities of the region. For example, in Lebanon, NGO's have been pivotal in delivering relief and humanitarian assistance to the population, especially during the period of conflict, and continue to develop successful collaborations with other organizations in the delivery of immunization services, distribution of medicines and health education for school children in collaboration with the Ministry of Education NGO involvement in public health activities in the various countries of the region, however, has been uneven. But evidence of strong partnership with govemment exists in all countnes and may form the basis for further collaboration and partnerships with development agencies such as the Bank in addressing public health issues in the region. 5.3.Bank Assistance In the coming years, the health systems of countries in the MENA region will face major challenges. Economic development in the region remains uneven, economic and political situations are volatile, and today countries are at substantially different stages of the health transition. Under these circumstances, the World Bank MENA Health Group has been developing projects in conjunction with its client countries to tackle overarching sector reform issues that aim at improving health outcomes in the region, adapting to the changing role of the state, enhancing the performance of public and private health care delivery systems, improving access and equity, expanding formal health insurance coverage, increasing private sector efficiency, and assuring long-term financial sustainability 5.3.1. Current Agenda The World Bank MENA Health team currently manages fifteen projects in the heal th, nutrition and population sector. These projects address a broad range of health systems development issues including: targeted interventions in family planning and communicable disease control (e.g., schistosomiasis control); strengthening hospital and clinical management capacity; upgrading health infrastructure and management information systems; and health sector reform programs that encompass substantial restructuring of health care financing and delivery systems. There are operations in nine countries: Djibouti, Egypt, Iran, Jordan, Lebanon, Morocco, Yemen, Tunisia and the West Bank and Gaza. The Bank Health Group has also provided direct technical assistance to Bahrain, Oman, Saudi Arabia, and the UAE. Active policy dialogues are underway in Al geria and Syria, and project preparation for health sector development and HIV/AIDS control are in progress for Djibouti. A health sector reform project has also been developed for Yemen. In addition to country specific projects, the Group actively supports regional knowledge dissemination activities such as hosting a regional seminar on Health Sector Development and a series of Regional National Health Accounts conferences. A regional HIV/AIDS strategy is being developed with funds from the Dutch trust fund, but much more needs to be done, especially by the Bank, considering the rate at which HIV/AIDS infection is increasing in the region. The Bank has also conducted regional reviews of nutrition and reproductive health. However, the current Bank portfolio needs to more effectively address the public health needs identified here, i.e., persistent communicable disease burden, the increasing burden of expensive-to-treat chronic disease and injuries, and emerging diseases. These changes require efforts to promote healthy lifestyles and intensify chronic disease and injury prevention programs especially in the middle- and high-income countries. Page 39 5.3.2. Gender Initiatives The Bank is also expanding its activities in the MENA region to include dialogue on gender iss ues and to build a gender dimension into lending operations. In fiscal year 2000, the Bank committed to a program of regional training on gender awareness for client countries as well as Bank staff The program's top priority is improving the status of women in rural areas, with a focus on education, health, employment, and legal status. Examples of Bank support to MENA countries that address gender concerns are * Nearly half of the small-scale subprojects implemented in the West Bank and Gaza's NGO Project cater to women's practical needs (kindergartens, educational services for women, prenatal care, and childcare), and a number have been directly implemented and managed by women; and * In the Republic of Yemen, the Child Development Project supports com munity schools for girls and offers incentive packages to schools that enroll the highest proportion of girls 5.3.3. National Health Accounts Initiative The World Bank, WHO and USAID have undertaken a joint initiative that creates regional networks to help countries to train personnel and develop their own NHA systems. Efforts are being made to institutionalize NHA systems and to make them a routine part of the health system. Recently, The World Bank/WHO/USAID organized 5 workshops and provided technical assi stance for defining and developing NHAs for the following countries in the region: Morocco, Tunisia, Egypt, Jordan, Iran, Yemen, Lebanon and Djibouti The workshops were initiated in January 1999 and held until June 2000 Another workshop was held in Morroco in April 2002 Algeria and the West Bank and Gaza are currently working on developing their National Health Accounts systems, as are several GCC countries. 5.3.4. Other Bank Activities Other Bank activities include (a) taxation studies on tobacco, shisto somiasis project and Health Sector Refonn in Egypt; (b) Family Health Project in Yemen; (c) Family Planning, Nutrition and Primary Health Care Projects in Iran; (d) Health Management Project in Morocco, (c) Health System Development Project in the West Bank and Gaza, (f) Health Sector Reform in Jordan; (g) Health Sector Management Project in Tunisia; (h) HIV/AIDS and Health Sector Development Projects in Djibouti; and (i) Health Sector Refonm Program in Yemen (annex B). The projects in Djibouti and Yemen are expected to begin in 2002 The HIV/AIDS Project in Djibouti is part of the World Bank's Multi-country AIDS Program (MAP) for Africa, and is intended to support the development of community action programs to combat HIV/AIDS, and increase the avallabill ty of care for other sexually transmitted infections (STIs) and HIV/AIDS opportunistic infections such as tuberculosis. The project will also support the National Malaria Control Program in Djibouti The Health Sector Development Project will assist the government with the selective implementation of pnority refonns targeted at improving the availability, quality and efficiency of health services in Djibouti. Other areas of Bank Assistance include human resource development, rationalization of the pharmaceutical sector, health financing and financial sustainability. Page 40 5.3.5. Role of the World Bank in Future Public Health Strategies The role of the World Bank in public health is to: (a) manage and disseminate knowledge on public health and public health functions; (b) conduct analytic work related to public health functions; (c) selectively engage in global health initiatives that will help countries make measurable progress towards their HNP goals, (d) build capacity for poverty reduction; and (e)improve Bank and client performance. Specifically, the role of the Bank in improving health in MENA is in its capacity for policy dialogue and resource mobilization. Because of its access to Ministries of Finance and Economic Planning, as well as functional Ministries for health, education and women's affairs, the Bank has the capability of facilitating synergistic policies that link investments in different sectors to achieve optimum impact on health. Strengthening partnerships with other agencies that are active in public health will help the Bank improve effectiveness in its operations. In collaboration with other development agencies, the Bank can also support the development of disease and behavioral surveillance systems throughout the region. It can also he lp to establish public health training programs or support the training of public health personnel, leading to the availability of a cadre of skilled public health personnel and leadership, who are able to support the information systems and effectively use the information to improve public health. Also, the Bank can support the conduct of applied research of critical issues, which will provide new information needed to improve the effectiveness of public health programs and policies. For example, in coll aboration with other agencies, the Bank can support research which identifies risk factors for disease and injury in different cultures and settings, and develops and evaluates effective public health interventions adapted to those settings. With Bank support, countries need to refocus on reproductive health issues as an unfinished agenda. Improving reproductive health requires improvement in the overall health system, including health promotion efforts, service delivery, quality monitoring, and institutional and technical capacity building. Reproductive health issues should be discussed with governments in the context of economic and social development The Bank also needs to provide additional assistance to countries for: (a) strengthening basic health services, supporting the development of public health infrastructure including disease and behavioral surveillance systems and human resource and capacity development; and (b) mobilizing partners and resources in the development of a regional public healt h surveillance system. The Bank can also assist in coordinating and mobilizing the technical and financial resources of other agencies such as the WHO, UNFPA, UNICEF, and other bilateral agencies, as well as non - govemmental organizations (NGOs) and the p rivate sector. Page 41 6. Conclusions and Recommendations The demographic and health profiles elaborated in this document portray the development challenges the region faces at the start of the 21st century The immense increase in the older population in the MENA region expected over the next 20 years presents enonnous challenges to public health efforts This challenge is greater than the simple increase in the total volume of discrete diseases associated with older age The average productivity of the ent ire population is compromised if efforts are not adopted to support, or better yet prevent, the potential dependency needs of large numbers of elderly. In the low- and lower middle-income countries of the region, there is a need to improve the delivery of basic health services. This situation might require restructuring the health system, strengthening basic health programs such as the expanded program on immunization, provision of maternal and child health services such as antenatal care, health promoti on and disease prevention education programs, and the integration of these basic public health programs at the first level healthcare delivery system and at the community level. These basic public health interventions are so cost effective with broad extenalities that countries at all levels of development must ensure that public health services are provided at reasonable standards Other secondary prevention/intervention programs, which are considered personal health services such as screening for STis, diabetes and other chronic diseases, as well as the provision of mental health services, ought to be made fairly accessible to the community and subsidized by the government. Financing of these basic public health services ought to be borne primarily by government, with the support of other development agencies, NGOs and private organizations. It will be the responsibility of governments to create the enabling environments for the development of strong partnerships with the private sector in the provision and financing of public health activities. Djibouti and Yemen, both low-income countries, have the least responsive and worst perfonring health systems in the region. While health systems and primary health care services need to be improved, and cost-effective public health programs need to be developed and implemented in the low- and middle income countries, concurrent and systematic efforts must be made to prevent increases in chronic diseases and injuries, as these will burden the already fragile heath system and drain the health sector of scarce resources needed to provide basic health care for the population. Chronic diseases are strongly related to lifestyle factors associated with rising incomes and affluence, and often result from a combination of genetic, environmental, sociocultural, and behavioral risk factors (the most modifiable of these are the behavioural risk factors). Most intervention efforts to effect changes in long -tenn chronic disease outcomes ought to address these personal risks The main behavioral risk factors associated with chronic diseases are tobacco use - mainly smoking, high fat diets, alcohol abuse and lack of physical activity. Although tobacco is a major contributor to the chronic disease burden in the region, tob acco control activities are not well developed, and there is relatively modest political support for the implementation of effective tobacco control measures. In some countries, officials of the WHO assist the Ministries of Health with health education and promotion programs. It is necessary for countries to take preventive measures to promote and support patterns of personal behavior and diet that can prevent chronic diseases from becoming epidemic. Many of the sociocultural factors that influence the development of chronic diseases are also tied to macro level variables, such as poverty, social status, education and income. Thus, the development of effective public health strategies in MENA becomes a challenge because of the diversity in the socioecono mic conditions of countries in the region. The challenge is for governments to develop and implement appropriate health promotion and disease prevention programs to reduce the incidence of expensive -to-treat non- communicable diseases and injuries. Page 42 Although injuries are a growing problem in most countries of MENA affecting the most economically productive age group, the magnitude of the injury problem is not fully appreciated. Also, international assistance to combat injuries pales in comparison to assis tance for other public health interventions. There is a need to train personnel in injury prevention. Leadership for injury prevention should be found within government and at ministerial and local levels. Regional and intemational collaboration is essential to accelerate the development of effective tobacco control programs in the region, since it is a major risk factor for chronic diseases. Public Health Infrastructure The future of chronic disease amelioration, injury prevention, communicable and e merging diseases control will require a complex public health infrastructure to provide public health services effectively. This includes the resources needed to deliver the essential public health services to every community, i.e., adequately trained pub lic health personnel, information and communication systems for collecting and disseminating accurate data, and public health organizations at the national and regional levels. Issues with current public health infrastructure in most countries of the region include fragmentation of services, implementation of multiple vertical programs with poor coordination (e.g., STIs, TB, MCH, family planning, HIV/AIDS, etc.), and lack of information on the effectiveness of the various programs. Traditionally, public h ealth activities have been developed and implemented within institutions, typically the Ministries of health. Increasingly, public health activities require management among institutions with community involvement. Clearly, there is a need for an integra tion of public health programs within and outside the healthcare system. Such approaches are more likely to be cost effective. While it is certain that all these issues are critical concems for the building of a sustainable public health infrastructure, it is unclear whether there is sufficient awareness and political will to address chronic diseases in the poor and lower middle -income countries of the region given the continued burden of communicable disease morbidity and mortality. Striking the right balance between the 'unfinished agenda' of communicable diseases and chronic conditions is a difficult challenge in the context of limited resources. The response of public health agencies should be to develop partnerships to aid the development of a regi onal public health infrastructure in order to address the issue of chronic diseases, injuries and emerging diseases, as well as the unfinished communicable disease agenda. There needs to be significant cooperation at various levels of govermnent as well as with non-govemmental agencies, intemational organizations and the private sector. Information Systems In assessing the scope and burden of disease and death associated with various health conditions in MENA, it has become apparent that the paucity o f data is a major setback to the development of evidence-based strategies for improving the public health situation in the region. Although many upper and lower middle-income countries have a reasonably well developed system of vital statistics for communicable diseases, most countries have not developed or implemented systems to track chronic diseases. In addition, very few countries, if any at all, have sophisticated methods of obtaining surveillance data on behavioral risk factors. Thus, there is a la ck of basic action on the leading behavioral factors associated with the major chronic diseases The maintenance of a reliable chronic disease registration system is technically complex and expensive, however, it is necessary to begin efforts to invest in a regional non-communicable disease database as a knowledge base for informing regional public health strategies Page 43 Public Health Financing In most countries of the MENA region, financing of public health services is largely limited to the provision of highly cost-effective services primarily relating to maternal and child health care such as immuniization, antenatal care, family planning services, control of communicable diseases and health education relating to these. These services do not address othe r problems of youth and the aged such as injuries, chronic diseases and emerging diseases such as HIV/ATDS Considerinlg the high cost of treating chronic diseases and injuries in particular, their economic burden in future is likely to have a devastating impact on the economies of developing countries if efforts are not made to prevent these conditions before they occur in epidemic proportions Investments in chronic disease and injury prevention, as well as emerging diseases such as HIV/AIDS, are likely to be highly profitable and cost effective, and ought to be given serious consideration by all countries of the region. Evidence suggest that chronic conditions affect the poor more than the rich, and place the poor at a clear disadvantage in addressing t hem Financing of secondary prevention programs such as mammography, STIs, diabetes and cardiovascular disease screening, though considered personal health services, are all imiportant public health activities that can be partly subsidized by government as well as private organizations and personal resources This is in accordance with the notion that public funds should be used to finance public and semi-public goods that are cost effective and for which demand is limited. Public funds should also be used for interventions that benefit the poor but are otherwise costly and unaffordable as are most secondary prevention personal health services, when contributory insurance is not likely to work.4' Assuring financial access to these personal health services by effective 'risk pooling' (i.e , health insurance schemes) through public and/or private financinig mechanisms could encourage their utilization by the population in order to prevent long -term costly tertiary care. Issues relating to appropriate public -private mix in financing these public health services have important implications for public health policy and can be supported by effective regulation to enhance equity and assure financial accessibility to these services. Given the important inter-sectoral linkages of health with education, poverty, housing, transportation, environimient, etc , public health financing must be considered in a broad inter -sectoral context 42 Very few resources are often devoted to the development of public health infrastructu re or to public healtlh functionls that are required for strengthening the capacity of the health sector and the sustainability of public health activities (i.e., fonrnulationi of policies, planning, program development, monitoring and evaluation of health interventions and programs, and research and traininig). There are other issues with public health funding that have to do with the image/perception of public health, such as public health being limited to funding from public resources, and public health excluding personal health services. Such erroneous impressions may need to be addressed to reduce limitations on public health funding General recommendations In all countries of the region, there is a need to. * Develop a comprehensive and effective Publi ic Health Agenda with set priorities which strikes the right balance between the unfinished agenda of communicable diseases and emerging chronic conditions; * Develop national and regional Public Health Infrastructure and fonn partnerships to address public health issues, which will vary depending on the situation in each country; Page 44 * Develop public health leadership and capacity to perform core public health functions; * Develop policies for addressing priority public health needs at the national level taking into consideration the stages of the countries in the demographic and epidemiological transitions; * Allocate funds for public health activities within national budgets; * Establish disease surveillance and information systems to monitor the health situation; * Gather country-specific data on communicable and non-communicable diseases and injuries, and collate data at the regional level for informing public health policy and strategies at both levels; * Intensify health promotion and disease prevention efforts, and develop the capacity to engage in related activities, and * Conduct research on cost-effective assessment of various public health interventions. Specific recommendations 1. Implement targeted and integrated cost-effective public health intervention programs to reduce: (a) vaccine preventable diseases through an intensified EPI program; and (b) communicable diseases (ALRI, diarrhea, malaria and tuberculosis) through the provision of primary health care and social services such as improved water and sanit ation facilities, and the implementation of effective environmental health policies, especially in the low - income countries of Djibouti and Yemen, and the lower middle -income countries of Iraq, Morocco, and Egypt. 2. Improve basic health services delivery and accessibility, especially in low- and middle- income countries of Djibouti, Yemen, Iraq, Morocco and Egypt. This might require restructuring of the health system by: * Improving the delivery of basic public health services such as the EPI, MCH services such as antenatal care, health promotion and disease prevention education programs; * Improving accessibility of public health services; * Integrating basic public health programs at the first level of the healthcare delivery system and at the community level; * Financing of basic public health services by government with the support of other development agencies, NGOs and the private sector; * Subsidizing secondary prevention programs and personal health services such as screening for STIs, diabetes and other chronic diseases and mental health services. Page 45 3 Implement appropriate nutrition intervenition programs to improve the nutritional status of young children in the region by: * Promotinig breastfeeding and appropriate infant weaning practices to improve child health; * Implementing targeted BCC programs to improve infanit feeding and child care practices, * Improving maternal healthcare services to reduce the incidence of low birth weight, * Intensifying IDD control programs through educationi and expanded distribut ion1 and accessibility to iodized salt, and * Obtaining data on the extent of micronutrient deficiencies (iron, iodine, vitamin1 A) among children to form the development of targeted inteivention stratcgies. 4 Develop and implement culturally sensitive reproductive health policies aimied at reducing fertility and matenmal mortality, and improving the status of women. Specifically develop strategies to: * Reduce adolescent fertility; * Reduce matemal mortality by strengthening the health care system at all levels improving access to emergency obstetric care, and improving coverage and quality of skilled attendance at birth; * Make reproductive health services available and youth -friendly by providilg family planning services and making the services accessible to youth including counseling on contraception, STDs and pregnancy, * Promote girls education, and * Promote the participation of women in income generating and communllty development activities, as well as in local decision -making. 5. Develop and implement appropriate health promotion and disease prevention programs to reduce the incidence of expensive-to-treat communicable and non-communicable diseases in all coLintries of the regioni by * Developing/Intensifying HIV/AIDS prevention programs in all countries of the region, especially in Djibouti, which has about 12 percent of its adult population living with HfV/AfDS - Develop capacity at country level to foster private/public collaboration, including legal regulatoiy modalities to enhance access to cheaper HIV/AIDS drugs; * Promiioting and supporting patterns of personal behavior and diet that caml prevent chronic diseases from becoming epidemic, Page 46 Public Health in MENA: A Situation Analysis APPENDICES Page 3 of 25 Appendix 2b: Health Expenditure, Services and Use, 1990-1998, Middle East & North Africa Physicians Hospital Bed Inpatient Average Outpatient Health beds occupancy admission length of visits expenditure rate rate stay per capita Country per capita per 1000 per 1,000 (US°/O) people people (°/) % of population days 1990-1998a 1990-1998 I 1990-1998a 1990-1998b 1990-1998a 1990-1998 a 1990-1998a Low-income Yemen 1 20 1 02 ] 07 -- a I Djibouti 56 -- _ - -- ._________ Lower middle-income Egypt 48 2.1 2 0 37 3 6 4 Morocco 56 0.5 _1 0 45 3 3 Algeria 62 0.8 2 1 50 West Bank and Gaza 122 0.5 1.2 52 9 3 4 Iran 107 0 9 1.6 54 Iraq 0 6 1 5 Jordan 134 I1.7 1.8 60 11 3 3 Tunisia 105 0 7 1 7 648 Lebanon 499 2.8 2 7 56 14 4 Libya 1.3 4 3 Upper middle-income Syria 1 4 1 5 Oman 222 13 2 2 58 9 4 4 United Arab Emirates 396 1 8 2.6 52 11 5 Kuwait 666 1.9 2.8 Saudi Arabia 352 1.7 2 3 11 11 l Middle East & North Africa 117 1.7 5 8 4 Low icome 1.0 1 8 5 13 3 Middle income 1.8 43_ 10 11 5 High Income 2.8 7 4 15 16 8 Europe EMU 3.2 7 9 18 13 6 Europe & Central Asia 3 6 10 1 17 14 6 Latm America & Caribbean 1.4 2 4 2 East Asia & Pacific 1.4 2 1 4 15 5 Sub-Saharan Africa 1 2 4 South Asia 0 4 0.7 3 Global _ 1.4w 3 8w 9w 14w 6w Source. 'World Development Indicators 2000, World Bank D World Bank Estimates WDI 2001 (unpublished) Note a Data are for the most recent year available Public Healthl in MENA: A Situation Analysis APP'ENDICES Page 4 of 25 FIGURE 9 GLOBAL TRENDS IN PHYSICIAN NUMBER, MID 1990S 6.5 6.0 c 55 0 X 5.0 0. 4.5 O 4.0°_ 0 40 Ci 3.5 CL LO 2.5- . 2.0 (.2 U 1.5 aL 1.0 0.5-. - 0.0 100 8w t1,oo0 G 10,000 100,000 Per Capita GDP, US$ FIGURE 1 0 GLOBAL TRENDS IN BED CAPACITY, MID I 990S 18- 16 - C14- 0 12 - .. o 10 - = WHOl \ * - 06 ° 8- . ,~~ * a,.s i 0 4-. I./ 10 100 1,000 10,000 100,000 Per Capita GDP, US$ Public Health in MENA: A Situation Analysis Appendices Page 5 of 22 Appendix 3: Health Expenditure Patternsa GDP Health Health expenditure Public share per capita expenditure as % of GDP of healtih per capita expenditure Counitry (USS) 1990-1998a (US$) 1990-1998 1990-1998a Public Private Total (% Total) Low-income Yemen (1998) 380 20 2 3 3 0 5 3 [ 42 DI ibouti (I1998) 807 56 | 5 4 | 1 6 | 7 0 77 Loxw!r middle-income Egypt, Arab Republic (1997) 1,252 48 1 8 2 0 3 8 47 Morocco (1998) 1,284 56 1 3 3 1 44 29 Jordan ( 1998) 1,732 134 5 5 3 9 9 4 58 Algeria (1998) 1,605 62 2 8 1 0 3 8 73 West Bank and Gaza (I1996) 1,423 122 4 9 3 7 8 6 57 Iran, Islamic Republic (1998) 1,650 107 1 7 2 5 4 3 39 Tunisia (1998) 2,126 105 3 0 2 9 5 9 5 1 Lebanon (1998) 3,839 499 2 2 10.2 12 4 20 Upp er middle-income Syria (1998) 1,118 0 8 17 2 5 32 Oman (1998) 6,500 222 2 8 06 34 81 Saudi Arabia (1998) 6,522 352 4 3 1 1 5 4 80 Bahrain (1998) 8,320 430 3.7 1 5 5 2 71 Qatar (1997) 17,511 835 3 7 2 8 65 57 Kuwait (1997) 16,510 666 2 9 04 3 3 88 United Arab Emirates "(1997)/1998) 19,112 855 2 7 1.5 42 36 Middle East & North Africa 117 2.4 2.3 4.8 50 Low income 23 1.3 2.8 4.2 31 Middle income 199 3.1 2.6 5.7 60 High income 2585 6.2 3.7 9.8 63 Source a World Development Indicators 2001 The World Bank Washington DC 2) World Bank Estimates, 2000 World Health Report 2000, WHO, Geneva Notes a Figures in this table are taken from the latest available data between 1990 -98 *Including the Gulf States FIGURE 1 IA: PUBLIC SHARE OF HEALTH EXPENDITURE AND INCOME LEVELS, MID 1990S 120% - 100% . 80% w 60% _ z 40% * - - L 20% . r\ . 0% 10 100 1,000 10,000 100,000 per capita GDP, US$ Public Healthl in MENA: A Situation Analysis API'E NDICES Page 6 of 25 FIGURE I I B PUBLIC SHIARE OF TOTAL HEALTH EXPENDITURE AND INCOME LEVELS, MID I 990S 120% w 100% . . 80%-* . **........... .- C;60% - ...Q a..........*hl ˘r' 40%~~~~~~~~~~~~~~~~~~ 20% . ._ S4 0% III 10 100 1,000 10,000 100,000 per capita GDP, US$ FIGURE I I C' PUBLIC SIIARE OF TOTAL HEALTH EXPENDITURE AS PERCENT OF GDP, GLOBAL TRENDS_ 10%- . 8%- _ : 6% - \\ i ., // . . . 4% - R . - >;W rD2%-J. -- _4 0% 1 oo 1,000 10,000 10 0o per capita GDP, mid 1990s US$ Public Health in MENA: A Situation Analysis APPENDICES Page 9 of 25 Appendix 6: HIV/AIDS in MENA PopIlation 1999 Estimated number ofpeople living with HI V/AIDS Orphans Estimated AIDS deaths I_______ ______ __ _End 1999: all countries Country Adults | Adults andl Adults and Total 15-49 Adiults and Adults Adult rate Women Chiildren Orphans children, children, (_tlousantds) (thousands) children (15-49) (%) L (15-49) (0-14) cumulative 1999 cumulative Low income Dlibotit; 629 295 37000 35000 11 75 19000 1 1500 7200 3100 Yemen 17,494 7,613 900* 1 001*1 Lower middle-income Iraq 22,511 10,850 300* <0 01 * Syria 15,740 7,766 800* 001* Egypt 67,232 34,342 8100* 0 02* Jordan 6,482 3,120 660* 0 02* Morocco 27,874 15,147 5,000* 0 03* Tunisia 9,457 5,179 . 2,200* 0.04* Libya 5,477 2,790 1.400* 005* Algena 30,788 15,998 11,000* 0 07* Lebanon 3,227 1,729 1,500* 0 09* . _ Upper ntiddle-inconte Saudi Arabia 20,936 | 9,539 | | 1,100* 001* | Qatar 589 308 | | 300* 009* _ _ _ _ Oman 2,465 1_ ,094 r | 1,200* | 011* II* _ Kuwait 1,916 1.051 - | 1,300* 0 12* | Bahrain 605 337 500* 0 15* 11 . United Arab Emirates 2.395 1,250 | | 2,300* 0 18* | MENA 336,496 171,943 220,000 210 0.12 42,000 8,000 15,000 -- 13,000 Western Europe 401,691 192,558 520,000 520,000 0 23 130,000 4,100 9,000 -- 6,800 Eastem Europe & Central 391,537 195,811 420,000 410,000 0.21 110,000 15,000 500 8,500 Latin America & 473,388 252,270 1,300,000 1,200,000 049 300,000 28,000 110,000 -- 48,000 Caribbean 32,024 16,860 360,000 350,000 2 11 130,000 9,600 85,000 -- 30,000 East Asia & Pacific 1,477.678 821,647 530,000 530,000 0.06 66,000 5,200 5,600 -- 18,000 Sub-Saharan Africa 596,272 273,488 24,500,000 23,400,000 8 57 12,900,000 1,000,000 12,100,000 -- 2,200,000 South & S East Asia 1,920,326 993,466 5,600,000 5,400,000 0.54 1,900,000 200,000 850,000 -- 460,000 Global Total 5,958,849 3,082,548 34,300,000 3,000,000 1.07 15,700,000 1,300,000 13,200,000 2,800,000 8,800,000 * The proportion of adults (I5 to 49 years of age) living with HIV/AIDS in 1999, using 1999 population numbers Soumce UNAIDS Report, 2000 http /lwww unaids org/hivaidsinfo/statistics/june00/fact_sheets/index html Public Health in MENA: A Sitiation Analysis APPIENDICES Page 10 of 25 Appendix 7a: Tuberculosis Rates-Eastern Mediterranean Relion Tuberculosis rates' Case notification New .smear-positive ca. es Smnear-+ve Incidence Prevalence rates rates TB cases in per 100,000 thouisand (Per 100,000 population,) DOTS areas, Country people cases 1997 1997 1995 1998 1995 1998 1998 Bahrai -- -- 20 6 35 8 29 18 5 - Djiboutl -- -- -- 596 7 -- 272 6 1,697 Egypt 36 35 56 1 192 14 1 74 1.600 Iran 55 62 47 3 17 9 15 0 7 8 3,323 Iraq 160 56 134 1 139 1 57 5 40 6 299 Jordan II 1 88 6 1 33 1 7 110 Kuwait 81 3 19 9 31 1 104 10 2 -- Lebanon 26 1 32 7 22 9 6 5 7 7 -- Morocco 122 28 114 9 106 2 54 6 49 0 13,426 Oman 13 0 128 90 63 46 109 Saudi Arabia 46 14 -- 16 0 -- 8 1 -- Syria 75 17 310 348 91 104 542 Tunisia 40 6 26 6 23 7 13 9 12 8 -- United Arab Eniiratcs 21 1 -- 32 8 - -- West Bank and Gaza 26 1 8 5 1 7 1 0 0 8 -- Yemen III 31 96 0 733 24 5 29 0 3,004 EEMR 67* -- 39.4 49.5 13.9 15.8 41,037 Souice Global TuIbciculosis Control Report. 2000 Eastern Mediterrdilean Regionial lProfile (1998) AVpendix 7b: Tuberculosis Cases (Regional Profile - EMR (1998)) Country Populgation Notif te Cases New ss+ 1 % Case detection All types New ss+ cases estimated of new .+ cases thousands No. Rate No. Rate I a b c d e f d/f Bahrain 594545 213 358 110 185 145 ] 759 Djibouti 622 540 3 715 596 7 1 697 272 6 2 136 79 4 Egypt 65 977 506 12 662 19 2 4 915 7 4 10 513 46 8 Iran 65 758 186 11 794 17 9 5 105 7 8 18 010 28 3 Iraq 21 800 073 30 324 139 1 8 850 40 6 15 693 56 4 Jordan 6 303 527 385 6 1 110 17 290 37 9 Kuwait 1 810737 564 31 I 185 102 258 71 7 Lebanon 3191 309 730 22 9 245 7 7 376 65 2 Morocco 27 376 661 29 087 106 2 13 426 49 0 15 319 87 6 Oman 2 381 924 215 9 0 109 4 6 149 73 2 Saudi Arabia 20 181 178 3 235 16.0 1 644 8 1 4 217 39 0 Syria 15 332 717 5 342 34 8 1 593 10 4 5 750 27 7 Tunisia 9 335 492 2 211 23 7 1196 12 8 1 706 70 1 United Arab Emirates 2 353 122 773 32 8 -- -- 225 -- West Bank and Gaza 1 036 228 18 1 7 8 0 8 355 2 3 Yemen 16 886 755 12 383 73 3 4 896 29 0 8 444 58 0 Regional Total 474 680 166 235 042 49.5 74 882 15.8 282 129 26.5 Soiurce Global Tuberculosis Cotitrol Report, 2000 Eastern Mediterranean Regional Profile (1998) http H/www who intgtb/publications/globrep00/other/emlir xIs Public Health in MENA: A Situation Analysis APPENDICES Page 11 of 25 Appendix 8: Smokins- Prevalence and Tobacco Related Mortality from Cancer a Smoking Prevalence" (%) Mortality rate"' (10+years 1997-1998 Per 100,000 p oulation (Males) Country Male Female Trachea, lung & Lip, oral & bronchus cancers pharynx cancers Djibouti 75.0 10 14 6 24 8 Yemen 60 0 29 101.6 12 4 Tunisia 61 4 4 2 56 8 57 8 Syrian Arab Republic 52 8 9 101 1 8 5 Lebanon 52 6 * 101 0 8 5 Jordan 44 0 5 101 0 8 5 Algeria 43 8 6 6 614 Egypt 43.6 4 8 11 1.1 Iraq 40 0 5 58 3 18.5 West Bank and Gaza Strip 40.0 2.7 Morocco 30 0 10 80 6 19.7 Iran 24 8 4.7 17 7 22 4 Bahrain 22.4 0 9 57 5 15 3 Oman 13 2 0 2 19.9 9 3 Saudi Arabia 40.0 8 2 44 2 19 2 Kuwait 34.4 1 9 79 4 10 1 United Arab Emirates 24 0 1 57.5 15 3 Middle East & North Africa 44 5 Source Corrao MA, Guindon GE, Sharma N, Shokoohi DF (eds) Tobacco Control Country Profiles, American Cancer Society, Atlanta, GA, 2000 'Data is from latest year available Appendix 9: Prevalence of Smoking Among Adults Aged 15 and Over, by Region. 1995. Smoking prevalence (%o) Total smokers World Bank Region Males Females Overall (Millions) % of smokers East Asia and Pacific 61 4 33 413 36 Europe and Central Assa 57 26 40 145 13 Latin America and the Caribbean 40 21 30 95 8 Middle East and North Africa 44 5 25 40 3 South Asia (cigarettes) 21 1 11 88 8 South Asia (bidis) 21 4 13 99 9 Sub-Saharan Africa 29 9 18 59 5 Low-Income and Middle-Income 49 9 29 939 82 High-Income 38 21 29 205 18 World 47 11 29 1143 100 Source Galjalakshmi C K, Jha Prabhat, Ransom Kent, Nguyen Son (2000) Global pattems of smoking and smoking-attributable mortality In Prabhat Jha and Chaloupka F J (eds) Tobacco Control in Developing countnes Oxford University Press, New York, The World Bank, 2000 xI Source Tessier JF. Nejjan C, Bennam-Othmani M Smoking in Mediterranean countries Europe, North Africa and the Middle-East Results from a co-operative study Int ** J Tuberc Lung Dis 1999 Oct, 3(10) 927-37) "" Ferlav J, Paikin, DM, & Pisani P (1998) GLOBOCAN I Cancer incidence and mioritality worldwide [CD-ROM] International Agencyfor- Research on Cancer Public Health in MENA: A Situation Analysis APPENDICES Page 12 of 25 Appendix 10: Changes in Disease Burden in the Middle Eastern Crescent 1990 2000 Injunes Injunes 13% 5 Corn m unicable 40% Conrunicable 48% Non-Cacrnmnicable 390/% Non-Communicable 45% 2010 2020 Injuries 180 .X Currinnniable Injuries Communicable CommuniCableo c Non- 60% Communicable 53% Public Health in MENA: A Situation Analysis APPENDICES Page 15 of 25 Anpendix 12: Deaths bv Cause in the Middle Eastern Crescent BURDEN OF DISEASE (DEA THS) 1990 2000 2010 MIDDLE EASTERN CRESCENT Males Females Males I Females Males Females DEATHS (1000s) All Causes 2399 2154 2777 2324 3167 2491 I. Communicable, maternal, perinatal, and 980 964 878 813 690 617 nutritional conditions A Infectious andparasitic diseases 459 411 407 344 314 256 1. Tuberculosis 69 40 54 30 41 23 2. STDs excluding HIV 7 7 6 6 5 5 3. HIV - - 10 2 11 2 4. Diarrheal diseases 217 208 192 176 148 131 5. Childhood-cluster diseases 120 116 105 97 80 71 a Pertussis 27 26 24 22 18 16 b Poliomyelitis 2 2 2 1 1 1 c Diphtheria I 1 I - - - d Measles 49 47 43 39 32 29 e. Tetanus 42 41 37 34 28 25 6. Malaria 3 3 3 2 2 2 7. Tropical cluster diseases and 3 1 2 1 1 leprosy 8. Intestinal nematode infections - - - - - - 9 Other infectious and parasitic 23 21 20 17 15 13 B Respiratory infections 272 262 248 230 200 184 C Maternal conditions - 48 - 30 - 18 D. Perinatal conditions 201 194 182 169 143 129 E Nutritional deficiencies 48 49 42 41 32 30 II. Non-communicable 1123 1033 1521 1309 2003 1623 A Malignant neoplasms 126 102 187 133 274 174 I. Mouth and oropharynx cancers 10 6 14 7 19 10 2. Stomach cancer 12 9 17 1 1 23 14 3 Trachea, bronchus, lung cancers 24 6 50 14 90 19 4 Breast cancer - 13 - 16 - 21 5. Cervix uteri cancer - 8 - 10 - 14 6 Prostate cancer 5 - 6 - 8 - 7. Bladder cancer 8 2 l l 2 14 3 8. Lymphomas and multiple myeloma 6 3 8 4 11 5 9 Leukemia 7 7 9 8 11 10 10 Other cancers 33 26 44 31 59 40 B Other neoplasms 3 3 3 3 4 3 C Diabetes mellitus 28 33 31 36 33 39 D Endocrine disorders 8 9 9 9 9 9 E Neuro-psychiatric conditions 33 29 35 30 37 32 G Cardiovascular diseases 658 637 920 834 1224 1047 1. Ischaemic heart disease 319 291 462 401 630 520 2. Cerebrovascular disease 99 131 139 152 186 195 Public Health in MENA: A Situation Analysis APPENDICF S Page 16of25 BURDEN OF DISEASE (DEA THS) 1990 2000 2010 MIDDLE EASTERN CRESCENT Males Fentales Males I Feinmales Male% Femnales DEA THS (1000s) 3 Other cardiovascular 194 184 261 228 338 276 H Respiratomy disease 87 76 133 1 08 199 155 1 Chronic obstructive pulmiionary 42 32 71 51 112 80 disease 2 Other respiratory 40 40 54 49 74 65 / Digestive diseases 85 67 97 71 112 75 I Peptic ulcer 4 2 5 2 7 3 2 Cirrhosis of the liver 26 20 32 23 40 26 3 Appendicitis 3 2 2 2 2 2 4 Other digestive 53 44 58 45 63 45 J Gem_to-ur_ a_v d _seases 53 39 5_ 40 62 42 Mff Congential anomZahles 39 37 45 41 48 44 III. InjurieN 296 156 377 202 474 251 A Un intentional inj usies 442 57 176 72 219 89 I Road traffic accidenits 55 I S 7 1 20 98 29 2 Poisonings 8 4 1 0 5 1 2 7 3 Falls 8 3 1 0 4 1 2 5 4 Fires 7 8 8 1 0 9 1 2 5. Dr-ownings 20 8 23 9 25 1 0 6 Othier unmitentioiial injLiries 44 1 8 54 23 63 26 B Intenitionial i1yiil1es 154 100 202 129 254 162 I Self-inflicted injuries 32 14 43 19 55 25 2 Violence 25 14 32 17 41 21 3 War 97 72 126 93 159 117 Soutnce World Bank Estimates. 2000 Hurnan Development Network Development Data Group Public Health in MENA: A Situation Analysis APPENDICES Page 17 of 25 jA pendix 13: Leading CausesofDeath, Both Sexes, Global, 1998 Rank 0-4 years 5-14 years 15-44 years 45-59 years 60 years All ages Perinatal Acute lower Ischaemic heart lschaemic heart Ischaemic heart I conditions respiratory HIV/AIDS disease disease disease 2,155,000 infections 1,629,726 887,146 6,239,562 7,375,408 _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2 13, 4 29 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Acute lower Road traffic Cerebrovascular Cerebrovascular Cerebrovascular respiratory Malarna 2 rsiaoyMlrainjuries disease disease disease infections 209,109 600,312 600,854 4,247,080 5,106,125 1,850,412 _ _ _ _ _ _ _ _ _ _ _ _ _ _ Chronic Diarrheal Road traffic Interpersonal Tuberculosis obstructive respiratory 3 diseases injuries violence 407,737 pulmonary infectons 1,814,158 161,956 509,844 disease 3,452,i178 _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1,974 ,6523, 5 , 7 Sel f-inflicted Trachea/bronchus/ Acute lower 4Measles Drowning Sefinjuriced un Tr chabrnchus! respiratory HIV/AIDS 887,671 157,573 508,621 305,982 can8e6s ifections 228522 _Chronic Malaria Diarrheal Tuberculosis Cirrhosis of the Trachea/bronchus/ obstructive 5 793M,3l68 diseases 427,314 liver lung cancers pulmonary 793,368 ~~133,883 4734264,117 889.873 disease ______ ______ ___ _ ______ _____ __ ___ _____ ______ ____ ______ _____ 2 ,24 9 ,2 52 Congrmtal War injunes War injuries HIV/AIDS Tuberculosis Diarrheal 6 abnorl40484e9 57,285 372,935 214,571 570,513 2d2se03s2 Nephritis/ Ischaemic heart Perinatal nephrosis disease Lvr cancers Stomach cancers conditions 349,885 44,640 244,556 205,394 561,527 2,155,000 Pertussis Congenital Cerebrovascular Stomach cancers Diabetes mellitus Tuberculosis 8 345,771 abnormalities disease 205,212 426,964 1,498,061 43,056 195,98320,1 Chronic Inflammatory Cirrhosis of the obstructive Colon/rectum Trachea/bronchus/ 9 30etanus cardiac disease liver pulmonary cancer lung cancers 302,668 40,802 142,445 disease 424,463 1,244,407 - ,_____________ ______________ 203,192 Protein energy HIV/AIDS Drowning Self-inflicted Cirrhosis of the Road traffic 10 malnutntion 39,042 141,922 injunes liver injunes 214,717 3 178,478 355,615 1,170,694 Road traffic Nephntis/ Drowning Fires Fires Malaria 125,301 38,968 122,666 injunes nephrosis 1,1 10,293 172,312 307,832 STDs excluding Cerebrovascular Maternal Breast cancers Oesophagus Self-inflicted 12 HIV disease haemorrhage 132 238 cancers injuries 118,178 38,349 116,771 132,238 296,550 947,697 i Acute lower Ospau ie acr ese 13 War injuries Tuberculosis respiratory cancers L2ver cancers Measles 103,323 38,093 infections 117,352 295,756 887,671 115,100 _ Road traffic Interpersonal Rheumatic heart Inflammatory Diabetes mellitus Stomach cancrs 14 injuries violence disease cardiac disease S 82,429 34,938 104,635 104,855 268,545 822,069 Meningitis Leukemia Liver cancers Inflammatory Self-inflicted Cirrhosis of the .M15 60,198 34,503 1 03c,131 cardiac disease injuries liver S614 3,97,511 227,724 774,563 Source World Health Report 1999 Database Public Healtih in MENA: A Situation Analysis API'ENDICES Page 18 of 25 Apendix 14: Leadin Causes of Burden of Disease, Both Sexes, Global 1998 Rank 0-4years 5-14 years 15-44)years 45-59years 60;years A11l ages Peniiatal Falls Unipolar major Ischaemic heart Isclhaemilic heart AcLptol I cond8tions 10,956,652 depression disease (isease rcspiratoiy 80,558.861 10_956652 , 48,723,776 15,184,630 29,028.308 i4tectio9s __________________ ~~82,344.294 Acute lower Road tiaffic Cerebrovascular CerebioV..ascular Perinatal 2 respiratory injuries I-1IV/AIDS disease disease conditions infections 8,701,689 45.990.984 10,835,472 20,431,975 80,563 550 64,228,262 871694.9.8 Acute lower Road traffic Chionic Chronic 3 Diarrhcal diseases respilatory njuries obstnictive obstructive Diarrheal diseases 61,928,529 infections 22i817i459 pulmonary disease pulimioniary disease 73 100 467 8,393,604 ,8, 7,737,631 13.856.850 Malaria Malaria Alcohol Unipolar majoi Dementias IIV/AIDS 28,377,796 7,786,061 dependence depression 5,345,048 70,929,569 Measles Drow niig Interpersonal Trachea/bronchUs/ Unipolai major Measle43 Drowning367 violence 7ste3a566 I Lung caticci s depression 25. 431,470 5,913,678 16,379,055 7,343,566 5,059,575 58,246,285 Congenital Self-inflicted Acute lower Ischacnic heart 6 Cabnongcmtalts Diarrheal diseases Tuberculosis respiratoiy licase a 0bnoma3lties 5,877,867 16,258,293 6,711 389 4,862,411 51,947 726 FIIV/AIDS Anaemias War injuries Cirrhosis of the Cataracts C crcbrovaseulat 18,802,590 5,233,961 15,074,260 5129e074 4.711,846 41,626,214 Protein energy Measles Bipolar affective Tiachca/bronchus/ Diabetes mellitus MalaI ia 8 malnutiitioni 4,726,253 disorder lug eancers 4117836 39,267,129 14,143,562 4762314,957,032 4,747,878 4.1,3 3.6.2 Pertussis Fires Tubereulosis Diabetes mellitus Tuberculosis Road traffic 9 11,740,117 4,354,125 14,213,396 3,772,964 3,749,742 38,848.625 10 Tetanus Tropical diseases Psychoses Cataracts Stomach canceis Meaisles 10,121,217 3,265,006 14,008,554 3,623,541 3,258,550 30,255,379 Chronic 11 HSTDs excludmng -IV/AIDS Anemia Stomach cancers Ostcoarthiitis obstructive 5,782,412 2,957,143 13,668,409 3,297,807 2,977,733 ptlinioiarv disease _______ _________ .___________.___ ______ _ .______ _ 28,653,713 Intestinal STDs excluding Road traffic Colon/rectuimrl 12 Falls neineatode HIV injuries caicei s TLbercilosis 5,635,576 inf2ctions 10,835,570 3,257,794 2,461,593 28,189,2 17 Obsessive Cirrhosis of'thc Congenital 13 Drowning Asthlima compulsive Liver cancers liver abnormalities 4,191,300 2,649,491 disorders 3,137,898 2.409.307 28,146,782 9,178,795 War injuries War injuries CerebrovasCular Self-inflictcd Unipolar major Fall. 14 3,942,734 2,578.041 disease injuries depiession 27,020,881 14___________ _ 3 227 1s8,121,363 2,841,741 2,064,100 Road traffic Nephritis/ Falls HIV/AIDS I-iver cancers Anemia 15 injur3es nephrosis 7.796,120 2,694,108 1,720.706 24.746,124 Souirce World Health Report 1999 Database Public Health in MENA: A Situation Analysis APPENDICES Page 19 of 25 Appendix 15: Leading Causes of Death, Eastern Mediterranean Region-High-Income Countries, Both Sexes, 1998 Rank 0-4 years 5-14 years 15-44years 45-59years 60 years All ages Diarrheal diseases Acute lower respiratory War injuries Ischaemic heart disease Ischaemic heart disease Ischaemic heart disease I 1 827 infections 1204 1.997 4 868 7 424 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _2 2 8_ _ _ _ _ _ _ _ _ _ _ Acute lower respiratory War injuries Road traffic injuries Cerebrovascular disease Cerebrovascular disease Acute lower respiratory 2 infections 145160 35infections 1713 1 5 6.0 1 2818 Perinatal conditions Self-inflicted injuries Ischaemic heart disease Trachea/bronchus/lung Acute lower respiratory Cerebrovascular disease 3 1 397 112 559 cancers infections 2 408 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _3 8 0 7 17 _ _ _ _ _ _ _ _ _ Measles Road traffic injuries Self-inflicted injuries Cirrhosis of the liver Chronic obstructive Diarrheal diseases 4 ~~~393 104 319 242 pulmonary disease 1 983 Congermtal Diarrhea] diseases Interpersonal violence Diabetes mellitus Diabetes mellitus War injuries _ abnonalitie366 91 260 227 310 1 825 Tetanus Inflammatory cardiac Inflammatory cardiac Inflammatory cardiac Trachea/bronchus/lung Periatal conditions 6 Ttnsdisease disease disease cancers 1397ttcodtin 6 _______________ _ 34487 183 203 262 1 397 Protein energy Cerebrovascular disease Cerebrovascular disease Chronic obstructive Inflammatory cardiac Road traffic injuies 7 malnutrition 71 172 pulmonary disease disease 923 269 _ _ _ _ _ _ _ _ _ 196 208 _ _ _ _ _ _ _ _ _ Rheumatic hatChronic obstructive 8 Pertussis Drowning heart War injuries Cirrhosis of the liver pulmonary discase 8 245etusi 58disease 181 183 797naydies 8 245 58 ~~~~~~~~~~~~~~~~148 797___ _ _ __ _ _ War injuries Rheumatic heart HIV/AIDS Road traffic injuries Nephritis/nephrosis Inflammatory cardiac 9 26disease 10775 disease 216 ~~~~~~47 101751758 Interpersonal violence Congenital Maternal haemorrhage Self-inflicted injuries Stomach cancers Trachea/bronchus/lung 10 84 abnormalities 107 147 cancers 84urce 45 107 147 10 693 Source- World Health Report 1999 Database. Public Health in MENA: A Situation Analysis AP1'ENDICES Page 20 of 25 Appendix 16: Leadin2 Causes of Burden of Disease, Eastern Mediterranean Re$ion-Hi2h-Income Countries, Both Sexes, 1998 Rank 0-4 years 5-14 years 15-44 years 45-59 years 60 years All ages Diarrheal diseases Acute lower r respiratory War injuries Ischaemic heart disease Ischaemic heart disease Acute lower respiratory I 2,1 infections 50233,5 513infections 62,214 ~~~~~8,943 50233,5 51375,853 Acute lower respiratory War injuries Unipolar major depression Cerebrovascular disease Cerebrovascular disease Ischaemic heart disease 2 infections 6,914 45,345 10,790 8,088 73,041 59,643 3 Perinatal conditions Road traffic injuries Road traffic injuries Unipolar major depression Cataracts War injuries 51,245 5,572 19,723 8,212 4,222 69,672 Congenital abnornalities Falls Psychoses Cataracts ChromcDiarrheal diseases 4 ~~~21,680 4,966 16,656 6,615 pulmonary disease 68,437 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _4 ,0 6 9 _ _ _ _ _ _ _ _ _ _ _ Protein- energy Anemia Bipolar affective disorder Trachealbronchus/lung Acute lower respiratory Unipolar major depression 5 malnutntion 4,608 14,704 cancers infections 54,660 115,984 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5,776 3,597_ _ _ _ _ _ _ _ _ _ _ _ _ 6 Measles Self-inflicted injuries Ischaemic heart disease Cirrhosis of the liver Diabetes mellitus Perinatal conditions 11,550 4,220 14,177 4,712 3,149 51.245 Tetanus Diarrheal diseases Anemia Osteoarthntis Trachea/bronchus/lung Road traffic injuries 7 11,517 4,104 12,728 4,514 1,563 29,979 Pertussis Inflammatory cardiac Drug dependence Benign prostatic Cirrhosis of the liver Cerebrovascular disease _ 8,452 3,362 11,000 4,479 1,227 28,685 War injuries Ccrcbrovascular disease Self-inflicted injuries Edentulism Tnflammatory cardiac Congenital abnormalities 9 8,252 2,671 9,928 4,130 disease 25,229 1,214 10 Falls Asthma Obstructed labour Diabetes mellitus Unipolar major depression Anemia 3,460 2,467 9,265 4,126 1,102 21,506 Source: World Health Report 1999 Database Public Health in MENA: A Situation Analysis APPENDICES Page 21 of 25 Appendix 17: Leading Causes of Death, Eastern Mediterranean Repion - Low- and Middle-Income Countries, Both Sexes, 1998 Rank 0-4 years 5-14 years 15-44 years 45-59 years 60 years All ages Perinatal conditions Acute lower respiratory War injuries Ischaemic heart disease Isc1aemic heart disease Ischacniic heart disease 1 272,167 infections 102,794 81,698 391,723 505,657 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _25,64 8 _ _ _ _ _ _ _ _ _ _ Diarrheal diseases War injuries Tuberculosis Tuberculosis Cerebrovascular disease Acute lower respiratory 255,388 16,568 54,837 33,568 141,148 339,817 Acute lower respiratory Road traffic injuries Road traffic injuries Cerebrovascular disease Acute lower respiratory Diarrheal diseases 3 infections 12,808 41,465 31,383 infections 275,848 . 237,732 . . ... _ _. ...___..._._- ... ._ 64,559 . . . . Measles Diarrhoeal discases Interpersonal violence Trachea/bronchus/lung Chronic obstructive Perinatal conditions 4 . 98,087 12,159 32,110 cancers pulmonary disease 272.167 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _14 ,038 4 4 ,6 74 _ _ _ _ _ _ _ _ _ _ 5 Pertussis Self-inflicted injuries Ischaemic heart disease Cirrhosis of the liver Tuberculosis Cerebrovascular disease 49,798 10,766 31,997 10,285 34,144 195,859 6 Congenital abnormalities Malaria Self-inflicted injuries Diabetes mellitus Diabetes mellitus War injuries 46,153 10,255 22,939 10,109 25,544 163,116 Tetanus Inflammatory cardiac HIV/AIDS Chronic obstructive Trachea/bronchus/lung Tuberculosis 7 disease pulmonary disease cancers 45,921 88813,898 9,0 994138,607 Malaria Drowning Cerebrovascular disease Inflammatory cardiac Inflammatory cardiac Measles 8 36,277 8,480 13,294 disease disease 96,087 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -____________________ 9,159 18,372 . .., . , X ._.. . ... Protein- energy Cerebrovascular disease Inflammatory cardiac War injuries Cirrhosis of the liver Road traffic injuries 9 malnui36,232 7,467 13,188 8,383 14,839 70,677 War injuries Tuberculosis Matemal hemorrhage Road traffic injuries Nephritis/nephrosis Chronic obstructive 29,205 5,583 11,904 7,464 13,627 pulmonary disease Source 62,918Health Report I 999 Database Sour-ce World Health Report 1999 Database Public Healthl in MENA: A Situation Analysis APPENDICES Page 22 of 25 Appendix 18: Leading Causes of Burden of Disease, Eastern Mediterranean Re2ion- Low- and Middle-Income Countries, Both Sexes, 1998 Rank 0-4 years 5-14 years 15-44 years 45-59 years 60 years All ages Perinatal conditions Acute lower respiratory War injuries Ischaemic heart disease Ischaemic heart disease Perinatal conditions 1 10,009,706 infction5s 4,145,089 1,387,448 1,965,555 10,009,706 1,004,458 Diarrheal diseases War injuries Unipolar major Cerebrovascular disease Cerebrovascular disease Acute lower respiratory 2 8,688,230 745,609 3,834,512 552,207 730,297 i 6fections Acute lower respiratory Road traffic injuries HI VIAIDS Tuberculosis Cataracts Diarrheal diseases 8,258,419 677,877 2,096,138 544,111 378,761 9,441,463 Measles Falls Tuberculosis Unipolar major Clhronic obstructive War injurieĥ 2,816,057 539,093 1,805,448 depression pulmonary disease 6,228,034 ______________________ ~~~~~~~~~~~~~~~~431,296 332,986 _ _ _ _ _ _ _ _ _ _ _ Congenital abnormalities Diarrheal diseases Road traffic injuries Cataracts Acute lower respiratory Ischaemnic heart disease 2,797,540 533,351 1,520,615 350,101 infections 4,427,032 _____________________ ~~~~~~~~~~315,057_ _ _ _ _ _ _ _ _ _ _ Protein- energyvAei scoe ibtsneltsTbruoi Unipolar major 6 mnalnutrition Anemia 1,263,359 Diabetes m6ellitus 250656 depression 2,144,129 426712339213750564,363,574 7 Pertussis Measles Bipolar affective disorder HI V/A IDS Diabetes mellitus HI WVAIDS 1,696,248 453,615 1,187,268 257,119 214,748 3,420,409 Tetanus Self-inflicted injuries Anemia Osteoarthritis Trachea/bronchus/lung Measles 1,535,610 406,508 1,098,772 239,463 cancers 3,420,409 Malaria Malaria Ischaemnic heart disease Chronic obstructive Inflammatory, cardiac Tuberculovis 9 1,295,873 382,217 1,066,029 pulmonary disease disease 3ub87u971 1,9,733221 ,6609225,468 105,459 3,8,7 War injuries Inflammatory cardiac Interpersonal violence Trachea/bronchus/lung Osteoarthritis Congenital abnormalities 10 1,116,517 339,316 1,010,585 2ancer6 98,923 3,109,068 Soutrce World Health Report 1999 Database Public Health in MENA: A Situation Analysis APPENDICES Page 23 of 25 Appendix 19: Life Expectancy at Birth 1999 D11bo i47 Iraq9 Egypt 67 Morocco 6 Lebanon i 70 LIbya 7 Iran 71 Algeria 71 Jordan 71 Palestine 7 Baran 73 Qatar 75 UAE 75 Kuw a t 77 OECD _ 77 0 1 0 20 30 40 50 60 70 80 90 Years Appendix 20: Infant Mortality Rates, 1999 OECO 6 UAE 8 Bahrain 9 Kuwait Oman 1 Qatar 18 Saudia Arabia 19 Ltbya m 22 Palestine _23 Tunisia _ 24 Ira n 26 Jordan 26 Syria 26 Algeria _ 34 Egypt _147 Morocco 48 Yemenan Iraq 1 01 Djibouti _ 106 0 20 40 60 80 100 120 Deaths per 1000 live births Public Health in MENIA: A Situation Analysis AIPENDICES Page 24 of 25 Appendix 21: Global Trends in Infant Mortality 180 - 160- 140 120 10 0 180 - 160 - 40- 20 - 0 . fa i * ; 10 100 1000 10000 100000 per capita GDP, US$ Aivrendix 22: Global Trends in Infant Mortality, 1999 180- 1601 140 120- 100 80- c60- 40- 20 - 0 10 100 1000 [mm. iooo0 100000 per capita GDP, LUS$ Public Health in MENA: A Situation Analysis APPENDICES Page 25 of 25 Appendix 23: Population Growth Rates, 1999 OECD ~~~~~0 6 | Tunisia13 Lebanon Algeria 1 5 Morocco 1 7 'ran 7 Egypt -_ Dj,bouti Om an 2 Lrbya 2i2 Syri Saud, Arabia Yemen 2 7 Kuwait 3 1 Jordan 31 Qatar 3 Bahrain 3 6 Palestine 3 7 0 0.5 1 1.5 2 2.5 3 3.5 4 Average Annual Population Growth Rate Appendix 24: Child Malnutrition-Underweight Lebanon _ 3 Jordan 5 Kuwait 6 Qatar _ 6 Bahrain 7 Tunisia 9 Morocco 9 Turkey 10 Iran E11 Egypt 11 Algeria 13 UAE 14 Saudi Araba a14 Djibou t _ 14 Oman 23 Iraq _25 Yeme n 3 0 10 20 30 40 50 Percent of Under-five Children Note: Data are for most recent year available Public Health in MEA'A: A Situiation Analysis ANNEXLS Page 1 of3 Annexes Annex A: Sources of Information Persons contacted for information in the preparation of this document include George Schlieber (Health Sector Manager), Anne Maryse Pierre-Louis (Lead Public Health Specialist), Christinia Djemmal (Operations Analyst), Joy De Beyer (Senior Health Specialist, -Tobacco), Edward Bos (Senior Population Specialist, Demography), Amie Batson (Senior Health Specialist, EPI program), Diana Weil (Public Health Specialist, Tuberculosis), Akiko Maeda (Senior Economist, Health), Eva Jarawan (Senior Health Specialist, Road Traffic Injuries), Nicole Klingen (Health Specialist), Qaiser Khan (Senior Health Economist), Karima Saleh (Consultant, Health), Jerker Liljestrand (Lead Health Specialist, HNP) Also contacted were the WHO website for TuberculosIs Initiative and Control; WHO EMRO website for Immunization Profiles, Globocan for Global Cancer Statistics; David V. McQueen, Associate Director, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta on Non-commllunicable diseases Information was also obtained from the World Bank Intranet websites and Image Bank. Thc World Bank's estimates are produced by the Human Development Nctwork and the Developmcnt Data group, in consultation with the Bank's operational staff and rcsident milssionls Additional information was obtained from the UNICEF, WHO, UNAIDS and USAID websites The Review of Nutrition and the Reproductive Health in MENA, both by Atsuko Aoyama were useful resources. A recent report on chronic diseases and injuries by David McQueen, Associate Director, National Center for Chronic Disease Prevention and Health Promotion also informed the preparation of this document extensively. All other sources of information utilized are listed in the References at the end of this document. Members of the World Bank's MENA Health Group, and the countries for which they werc responsible during the preparation of this review are shown here. George Schieber - Iran, Oman, Saudi Arabia Maryse Pierre-Louis - Morocco and Jordan Eva Jarawan - Lebanon Akiko Maeda - Egypt and West Bank and Gaza Nicole Klingen - Iran, Algeria, Djibouti Sameh El-Saharty - Tunisia, Yemen Qaiser Khan - Djibouti Public Health in MENA: A Situation Analysis ANNEXES Page 2 of 3 Annex B: Current and Future World Bank-supported Health Projects in MENA Total Board Project Name Project Id atount approval (US$M) sttsdate Primary Health Care and Nutrition Project (02) P069943 87 Iran Active 5/18/00 Health Sector Reform Project P039749 35 Jordan Active 3/25/99 Health Financing and Management Project P005525 66 Morocco Active 12/17/98 Health Sector Reform Project P045175 90 Egypt Active 5/21/98 Health Sector Loan Project P005746 50 Tunisia Active 3/10/98 Social Priorities Program - Basic Health Project P042415 68 Morocco Active 5/30/96 Population Project P005163 17.2 Egypt Active 3/21/96 Health Sector Rehabilitation Project P034004 35 7 Lebanon Active 12/20/94 Family Health Project P005910 26.6 Yemen Active 6/24/93 Primary Health Care & Family Planning Project P005222 141 4 Iran Active 3/25/93 Health Management Project P005319 20 Jordan Active 3/16/93 National Schistosomiasis Control Project P005152 26.84 Egypt Active 6/25/92 Education & Health Rehab WBG Health System Development WBG National AIDS Control Project P073603 12 Djibouti Pending Health Sector Development Project P071062 29 Djibouti Pending Health Sector Refonn Program P043254 80 Yemen Pending Public Healtht in MENA: A Situation Analysis ANNEXES Page 3 of 3 Annex C: World Bank Lending World Bank Fiscal Year (FY) 2000 Operational Results For the Middle East And North Africa Region New lending commitments from the World Bank to countries of the MENA region totaled US$950.4 million for 21 projects in 10 countries in FY2000, which ended on June 30, 2000 The Bank's lending commitments to the region included US$1902 million in concessional loans from the International Development Association (IDA), and US$760 2 million in market-based loans from the International Bank for Reconstruction and Development (IBRD). The total compares with US$1 7 billion in FY1999, and US$988 million in FY1998. Iran, which had not borrowed from the Bank since FY1994, was the largest borrower in the MENA region in FY2000 with commitments totaling US$232 million for two projects. Tunisia was the second largest borrower with commitments that totaled US$202 million. Lending to Algeria and Lebanon, which did not borrow from the Bank in FY1999, reached US$974 million and US$136 6 million, respectively. Lending to Egypt, Jordan and Morocco significantly declined in FY2000 from relatively high levels in FY1999. Egypt received US$50 million compared to US$550 million, Jordan received US$35 million compared to US$210 million, and Morocco received US$7 5 million compared to US$440 million Morocco also received a Global Environment Facility fund of US$9.8 million in FY2000 to support a Protected Areas Management project. Two countries in MENA benefited from IDA (the World Bank affiliate that provides interest free credits to the world's poorest countries with a maturity of 40 years, including 10 years grace) concessional lending in FY2002. Djibouti received US$15 million and Yemen, which had the largest number of projects (four) approved this year in MENA, received US$144.8 million Yemen also received a commercial debt reduction grant of US$15 I million in FY2000. The West Bank and Gaza, which draws its funds out of the World Bank's surplus income on standard IDA terms, received US$30.4 million in support of three projects Lending to support the human development sector (education, health, nutrition, population and social protection) have been increasingly part of the Bank's prime focus for its operations in MENA Bank's commitments to MENA's human development sector reached about US$390 million, equivalent to 41 percent of total lending this Fiscal year. Total IBRD and IDA lending for the MENA region reached about US$34 billion by the end of FY2000, with Morocco receiving the largest share of about 25 percent of the total. The major IDA beneficiaries are Egypt and Yemen, which cumulatively received in commitments up until June 30, 2000, about US$2 billion and US$1.8 billion, respectively. The World Bank has also committed, US$297 million to the West Bank and Gaza since FYI994 References I Institute of Medicine. Committee for the Study of the Future of Public Health, (1988). The Future of Public Health National Academy of Science. National Academy Press Washington D C. 2 World Health Organization Essential Public health Functions-their place in the health for-all policy for the 21s' century 1015 Session of the WHO Executive Board meeting 3Bettcher D, Sapirie S., Goon EHT (1998) Essential Public Health Functions results of the international Delphi study Rapp Trimmest. Statist. 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