Health Care in the Arab World: Outcomes of a Broken Social Contract

The 2019-2020 novel coronavirus outbreak has exposed the weaknesses in the health systems of even the most developed countries. Across the Arab world, where public health investment is notoriously low, these weaknesses have been made wholly obvious. Despite being home to some of the oldest continuously inhabited cities in the world­, such as Damascus, Jericho, Beirut, and Fayoum, most of the Arab states as recognized today were founded in the second half of the 20th century. These postcolonial states were constructed with central authority in mind, not social support and development; as they evolved, efforts to maintain these power centers focused the region on militarization, authoritarianism, conflict, and oil dependence.

The essence of a social contract between a state and its citizens is clear: the citizen has certain expectations about what the state delivers, including access to food and health care. In return, the state has its own demands and expectations of its citizenry. Yet globally, few world areas beyond the Arab region are as associated with poor governance, violent conflict and terrorism, weak institutions, and poor—sometimes even declining—social outcomes. While, for instance, the health systems in Syria and Saudi Arabia today are almost incomparable in their delivery and outcomes, they both reflect the inevitable development trajectory of a region with a weak social contract toward its citizens.

Arab Population Trends

The population of the Arab world has more than doubled since 1990, with approximately 400 million inhabitants1, excluding the large expatriate populations in the Gulf states. Broadly speaking, the Arab region has been in a period of some positive transition, with significant increases in life expectancy, literacy, and access to sanitation and electricity in the past several decades. But other regional trends bode poorly for public health in Arab states. More than three quarters of this population live within just eight countries, most of which are in some stage of political conflict: Algeria, Egypt, Iraq, Morocco, Saudi Arabia, Sudan, Syria, and Yemen.

Arab states are also disproportionately represented in global refugee figures, making up nearly 40 percent of the world’s 60 million displaced people.

Arab states are also disproportionately represented in global refugee figures, making up nearly 40 percent of the world’s 60 million displaced people. This is primarily due to protracted conflicts in Iraq, the occupied Palestinian territories, and Syria. Many of these displaced people have stayed within the Arab region, with Lebanon and Jordan hosting the highest number of refugees per capita. Population centers like Amman, Cairo, and Jeddah have experienced

significant growth as the region faces rapid urbanization and changes in family living dynamics, straining already under-resourced health systems. This regional instability, bolstered by poor governance, authoritarianism, neglect of social services, and corruption, has led to the inability of many Arab states to provide adequate health care.

Regional Health Outcomes

Arab states have a poor track record of investing in public health; the most recent data available from 2016 show that, on average, they expended just 5 percent of GDP on health, lower than the average for low- and middle-income countries as a whole (5.4 percent). At the same time, despite annual fluctuations in expenditure, many Arab states report the highest military burdens in the world. This emphasis on national security at the expense of human security has precipitated negative health effects throughout the region.

Often grouped together in geopolitical discussions, the 22 states of the Arab League are quite disparate in measures of health. The average citizen of Kuwait faces little risk of starvation, while Yemen has been under famine conditions since 2016 that have killed tens of thousands of children. Infant mortality rates in Somalia are nearly 15 times those in Qatar, according to the latest estimates in 2017. When adjusted for age, Oman reports a 9.6 percent prevalence of tobacco use, while Lebanon reports a 42.6 percent use rate. In the poorest Arab countries, the rate of deaths from HIV/AIDS increased by 274 percent from 2000 to 2015, while in the higher-income states, car accidents constitute one of the primary causes of premature death. Inequities within the region have been especially more pronounced since the Arab uprisings in the early 2010s.

Rates of mental illness have increased across the region, but citizens of the conflict-affected Arab states are much more susceptible. Drug and alcohol use, traditionally minimal in these majority-Muslim countries, is increasing.

Rates of mental illness have increased across the region, but citizens of the conflict-affected Arab states are much more susceptible. Drug and alcohol use, traditionally minimal in these majority-Muslim countries, is increasing. The political crises in war-torn Yemen, Libya, and Syria have lowered life expectancies, while Cairo has the distinction of having some of the worst air quality in the world. Infectious diseases are not new to the Arab region, especially in the poorest countries; outbreaks of cholera, tuberculosis, polio, leishmaniasis, malaria, hepatitis C, and others have occurred in recent years to varying degrees of severity. Prior to COVID-19, many Arab states had suffered similar effects from another strain of coronavirus that is thought to have originated in Saudi Arabia, the Middle East Respiratory Syndrome coronavirus, better known as MERS.

These disparities make clear that there is no singular regional policy regarding improved public health in the Arab region. However, there are some trends that guide our understanding of the state of health. Longitudinal studies of the region show some of the same health transitions as other regions with emerging economies. Communicable diseases have decreased due to increased vaccination efforts and improved sanitation and water services. Expanded access to food has led to reduced rates of malnutrition and underweight, especially in children. Maternal and infant mortality have declined while safe breastfeeding rates have increased. Today, as in much of the world, heart disease is the top cause of death for countries throughout the Arab world. This is indicative of an epidemiological transition that occurs when populations are less threatened by communicable disease and starvation and instead suffer from ailments related to lifestyle choices, like smoking and engaging in minimal physical activity. These health risks can be effectively countered with public health investment, health promotion, and reconsiderations of the political economy of these states as it relates to health. Yet Arab states still pursue an outdated model of health delivery that focuses on curative medicine and treatment, not prevention and self-management.

Today, as in much of the world, heart disease is the top cause of death for countries throughout the Arab world.

Additionally, care for the most marginalized groups—especially women, people with disabilities, and rural populations—is inadequate across the region. More so than any other area of the world, women in the Middle East suffer from depression as their leading cause of illness. Youth, who make up a third of the total Arab population, are also underserved. Lack of knowledge about sexual health across the Arab region has led to outcomes like high adolescent birth rates because of early marriage, due in part to cultural taboos about discussing such issues openly in schools or within families. These same taboos may be contributing to documented increases in youth drug and alcohol abuse, smoking, reckless driving, and overall poor health habits. As these youth come of age, such harmful lifestyle choices bode poorly for any chance of reducing mortality due to non-communicable diseases and other preventable threats to health.

The High-Income States of the Gulf

The oil-rich states of the Arabian Gulf—Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE)—constitute the most distinct group. Due to the financial stability afforded by their natural resources, they have undergone the epidemiological transition at faster rates than their regional neighbors. The most physically demanding labor has been relegated to migrants, and the exceedingly high temperatures encourage citizens to stay inside and tend toward sedentary lifestyles. Easy access to unhealthy foods, supported by the incursion of fast food chains and other elements of western diets, have also contributed to higher rates of overweight and obesity­—more than 60 percent across the Gulf states.

Despite their perceived abundance, many Gulf states are lacking in health care delivery. Rapid population growth has placed new pressures on their health systems.

Despite their perceived abundance, many Gulf states are lacking in health care delivery. Rapid population growth has placed new pressures on their health systems. While there have been investments in the health sector, increasing the number of facilities and providers, the states of the Gulf spend less on health care than countries with comparable development and income—3.8 percent of GDP as compared to a global average of 10 percent. Health services are generally provided free to residents and health insurance is available for foreigners. Yet up to half of residents of many Gulf states travel abroad for treatments unavailable in their countries, especially those needing specialists. In addition, high dependence on migrants for their health

care workforce means that despite investment, these states are still lagging in availability of providers as retention rates for expatriate health care workers are low. In the UAE, for example, only 3 percent of nurses are Emirati. Governments have tried to tackle these issues with initiatives targeting heart health, patient safety, and youth behaviors, among other issues. However, as populations continue to increase and age, a proactive approach will be required to maintain the quality of life of residents across the Gulf.

The Middle-Income States of the Levant and Northern Africa

By far, the largest subsection of Arab states comprises those in the middle of development and income indicators, like Jordan, Lebanon, Algeria, and Morocco. These diverse states, while not in active conflict, are often on the edge of political fragility. They are in various stages of progression through the epidemiological transition; some still feature a higher-than-expected mortality rate from issues related to poverty and infectious disease, but most of their disease burden has shifted to non-communicable diseases related to lifestyle. The states where the governments are at least moderately accountable to their people generally fare better in health outcomes as do the states with fewer social divisions and less ethnic fragmentation.

Aside from such differences, inequities within these states are also significant, especially between urban and rural populations, and dependent on age, educational level, and socioeconomic status. Most state health expenditure is for hospitals, which are the most expensive and least accessible forms of health care delivery. Additionally, the emphasis on hospitals has left these countries lacking in home health care, palliative and hospice care, long-term care, dental services, and mental health facilities. One area where several of these Arab states have rightly focused their efforts is on medication development, with high-quality factories in countries like Tunisia, Egypt, and Jordan. However, the lack of a cohesive regional pharmaceutical strategy depresses the development of a dynamic Arab pharmaceutical industry.

In middle-income Arab states, most state health expenditure is for hospitals, which are the most expensive and least accessible forms of health care delivery.

As some of these Arab states adopted an approach where “regime survival became a more important goal than development” and failed to respond to their populations’ needs, citizens looked elsewhere. Those who can afford private care utilize it, as it is often of higher quality than public facilities—but this exacerbates inequalities. Non-state entities like religious organizations and charities fill other gaps; Islamist groups like Hamas, Hezbollah, and the Muslim Brotherhood have leveraged their service provision to strengthen their popularity in weak states. Today, in the post-Arab Spring era, populations are more educated, connected through social media, and aware of their governments’ shortcomings. As a result, they are expecting more when it comes to health and quality of life.

The Region’s Fragile States

No analysis of the health of the Arab region is complete without an understanding of its fragile states. Protracted and complex conflicts in states like Iraq, Syria, Yemen, Libya, and the occupied Palestinian territories have decreased health outcomes there for some of the same reasons addressed throughout this analysis. However, conflict-specific factors like poorly served refugee populations, attacks on health care facilities and personnel, sanctions and blockades, and high rates of mental and physical trauma distinguish these states from their more stable neighbors.

In [fragile Arab] states, humanitarian agencies are not just filling gaps in care but may be the only care providers.

More citizens of these countries die from starvation, treatable diseases, and delays in care due to movement restrictions than from the direct violence of bombing campaigns and terrorist attacks. In Yemen, for example, less than half of medical facilities are functioning. In Iraq, the regime of Saddam Hussein had already reduced health expenditure by 90 percent from 1993 to 2003––partly due to imposition of western sanctions, thus destroying the country’s once-lauded health system; therefore, by the time the American-led invasion began, the country was already in a public health crisis. Dozens of Palestinian women have been forced to give birth at Israeli checkpoints, sometimes resulting in the death of the mother or child. In Syria, health care facilities were so persistently targeted by air strikes that armed groups avoided meeting near them to reduce their risk of being bombed. In these states, humanitarian agencies are not just filling gaps in care but may be the only care providers. As a result, health care in these countries is highly dependent on year-to-year funding fluctuations and accessibility to vulnerable populations; it ends up focusing on managing emergencies at the expense of building long-term capacity and infrastructure.

Regional Prescription

While evidence shows a panoply of health priorities throughout the region, there are standard recommendations that Arab states can undertake to ameliorate their health outcomes and preparedness for future health crises. Improving governance and reducing conflict would be the most significant reforms in terms of advancing population health, but the people of the Arab world cannot wait for political stability before tackling their health issues.

Significant structural reform is required across the region, one focused on a three-pronged approach. First, states must invest in health promotion and outreach, especially on issues like tobacco use, driving, healthy lifestyle choices, and issues deemed culturally taboo like mental and sexual health. Shifting from a curative to a preventive model would greatly reduce the disease burden from non-communicable diseases and other causes of premature death, mitigating the strain on healthcare systems. In areas where health-focused laws may exist, they are often flouted; for example, it is relatively easy in some Arab states for a child to buy tobacco or shisha. Regulatory policies must be strengthened and building community buy-in is a necessity. On the other hand, laws or norms that limit health autonomy must be challenged. For example, until recently, women in Saudi Arabia were prohibited from being admitted to a hospital without a male guardian.

Second, Arab ministries of health must invest in health information like consistent collection of vital statistics and adequate support for disease surveillance. Longitudinal health data is spotty from most Arab countries, indicating poor investment in public health. Yet, as the COVID-19 pandemic has made clear, the time for this investment is not after an emergency but well before. Limitations exist in the fragile states, especially Yemen and Syria, in terms of data collection, but where possible, these systems must be bolstered and processes should be made consistent and transparent. No adequate tracking can take place or needs determined without data.

Lastly, states and humanitarian agencies working in the states must shift to a long-term health infrastructure approach, including limiting the brain drain of health professionals; building infrastructure like medical schools, primary care clinics, and mental health facilities; and focusing on preventive care where possible. In the coming decades, as the youth of today age, the burden of non-communicable diseases that will be inflicted on the region will be overwhelming. If significant changes to population health efforts and infrastructure are not prioritized, there will be a massive health care crisis to which no ministry of health or humanitarian agency will have the capacity to respond.

1 This figure represents the cumulative national populations of the members of the League of Arab States.