Access to health care is concomitant with stable societies, but this stability is lacking in many MENA (Middle East/North Africa) region countries. Wherever one drops a pin, there is sure to be a conflict or a potential conflict nearby.
Major wars in the MENA region during the twenty-first century have already killed one million people by direct violence. The terrible impact of war on health care was uniformly identified by the participants as one of the greatest threats to public health in the MENA region. Moreover, destroyed infrastructure has made it difficult for a great number of people to access health care and has seriously threatened the safety of health workers.
The Covid-19 pandemic has greatly intensified the trauma of people in much of the MENA region. In war torn countries like Iraq, Libya, Syria, and Yemen, it has given rise to very urgent healthcare challenges. 22% of adults in conflict areas in the MENA region suffer from mental health conditions due to high levels of stress. These are caused by displacement, family separation and isolation, limited access to information for refugees and difficulty accessing health services.
In the face of Covid-19, several MENA countries, such as Algeria, Egypt, Jordan, Morocco, and Tunisia are grappling with intensified health system challenges—namely, health financing and delivery mechanisms—which have serious implications on access to healthcare services, equity, efficiency, quality of care, and, ultimately, upon health outcomes.
Forum of Ideas
Generous health care professionals, academics and grassroots activists took time from the demanding requirements of their work during the Covid-19 pandemic to contribute to the Forum on Equal Access to Health Care in the MENA Region held at the Geneva campus on June
3rd, 2021, from 9 am-6pm. A distinguished keynote speaker, four professional moderators and sixteen experts addressed the following themes (please see program)
· Healthcare & Armed Conflict
· Healthcare & Sanctions/Occupation
· Healthcare & Gender/Minorities/Youth
· Healthcare & COVID-19
At the outset of his keynote speech, Dr. Khalid Koser, Executive Director of the Global Community Engagement and Resilience Fund, laid a broad framework for healthcare across these themes. He identified education and health as global public goods and signalled the potential of the MENA region to become a vibrant a source of innovation in providing medicine and health care. Dr. Koser linked the lack of vaccine equality and weaponizations of health care to the rise of violent extremism.
During the height of the decade-long civil war in Syria, more people died from lack of access to health care than from direct violence. Only 42% live in areas that have sufficient health workers and more than 70% of health care workers have left the country, placing greater strain on those remaining.
Although violence has decreased since last year due to cease-fires, residents in parts of northwest Syria are caught in the web of a humanitarian catastrophe. Hospitals continue to be regularly targeted. Medical facilities are insufficiently equipped with oxygen, ventilators, and x-ray machines.
Due to this protracted violence, 60% of people in the northwest part of Syria lack sufficient food and water. Food prices have more than doubled. Unemployment is at 89%. 2.7 million people have been displaced. Tens of thousands of homes have been recently lost due to floods.
During the past 30 years, Iraq has been ravaged – by the Gulf War, U.N. sanctions, sectarian conflict, the rise of Islamic State (IS) and a massive influx of Syrian refugees. It has also been devastated by governmental decisions to deprioritize health. Although the conflict with IS has ended, the country remains very volatile and vulnerable. An estimated 4.1 million people need humanitarian assistance. Malnutrition is chronic, especially among children.
Economic sanctions imposed on Iraq from 1990-2003 exacerbated the fragile healthcare system that is now plagued by corruption, underfunding, and mismanagement. Although the National Health Care System is mandated to provide services for the multiple ethnicities religions and sects in Iraq, minorities do not have their basic rights respected. As a result, Iraqis have little confidence due to the underfunded health care system and the poor quality of its delivery.
Yemen is in dire need of humanitarian aid. Nearly 20 million people lack access to basic health services. Yemen has faced enormous challenges in providing health during the Covid-19 pandemic. The first of these is the naval blockade of the main ports.
In addition to collateral damage of conflict, Yemen has witnessed the flight of foreign medical professionals and decreased funding. The influx of migrants from Syria has further overwhelmed the health care system. Half of the hospitals have been shut down and malnutrition is severe.
The statistics are dire and the future outlook grim. In a population of nearly 30 million, approximately 16 million are severely food insecure—a global record. In June 2021, more than 400,000 children suffer from severe acute malnutrition. This deprivation has the potential to create irreversible stunting, wasting, and increased mortality.
Iran suffers from political authoritarianism, mismanagement,brain drain and a crumbling economy. The economic sanctions, which add another layer of complexity, are often used for geopolitical gains and as a tool of violence. Sanctions have forced Iran to develop a resistance economy, a thinly veiled metaphor for belt-tightening.
The impact of sanctions on health care in Iran is especially tragic for those who suffer from rare diseases. Moreover, sanctions have also reduced the purchasing power of the general populace due to increased inflation. Drug prices have risen. Scarcity has led to hoarding, black marketing, and corruption.
Health care management during the Covid-19 pandemic has relied upon on local, home-grown solutions, shared societal norms and a community-driven approach, all of which were implemented from the beginning of the Iranian Revolution. Iran is currently producing multiple vaccines, which may be available in the next few months
In the colonial context of Palestine, mobile health clinics cannot freely circulate due to a labyrinth of roads for colonial settlers only as well as internal check points. Permits are regularly semi-permanent structures, such as health clinics. The rights of Palestinian workers1 in Israel and illegal Israeli settlements in the West Bank have been the subject of increasing violations since the outbreak of the COVID-19 pandemic.
Inadequate medical care during pregnancy is the third leading cause of death among Palestinian women of childbearing age. Many Palestinian women face difficulties reaching their doctors because of internal checkpoints that separate cities and villages.
In contravention of international law, Palestinian prisoners are systematically denied medical treatment. Medical supplies (Covid-19 vaccines) and delivery of services are denied or delayed. Intentional bombing of health service buildings with state-of-the-art weapons aim to impair and terrorize.
The Gaza Strip has a population estimated at 734,547. It has a population density of 4,505 people per km2 and the highest unemployment rate in the world.
According to UN officials, healthcare in Gaza is at a precarious breaking point due to the military blockade, a divided Palestinian leadership, deadly armed incursions, and intense societal pressures.
Poorly paid health workers and inadequate hospitals have added salt to the wound of two million Gazans. Due to a badly depleted aquifer, only 4.03% of households have running water.
The October 2019 revolutions, extreme economic problems in Lebanon and the Beirut blast (4 August 2020) have resulted in economic catastrophe and extreme devaluation of the country’s currency. The currency has lost more than 90% of its value and unemployment has skyrocketed. The effects have been a significant increase in poverty, a decline in food security and a departure of skilled medical workers.
Women and girls have been made increasingly vulnerable by Covid-19. Domestic abuse has increased, as well as trafficking of women. There is an alarming Increase in adolescent pregnancies. Protection for victims is urgent, given that international law states that denial of health care to women and children is a violation.
Jordan has welcomed refugees since 1948 when 750,000 Palestinians fled to neighboring countries following the 1948 Nakba. During the decade long conflict in Syria, close to a million Syrians sought refuge. 88% are in a state of toxic stress, suffering from psychosocial stress related to the Covid-10 pandemic. Moreover, priorities are complicated by the fact that the overburdened healthcare service is managed by the Ministry of Defense.
Delivery of medical services to refugees as well as its own increasing populace is an enormous challenge. Jordanian hospitals are overcrowded and there is a great shortage of trained healthcare workers. Other challenges include an aging population, the increasing burden of chronic disease and unequal delivery of health services to vulnerable women. In addition, the Covid -19 pandemic has widened the gender gap in the economy.
Jordan’s mental health care community was very responsive to emerging needs during the pandemic. Greater use was made of remote psychological support, community training focal points, integration of information and psychological first aid.
The Moroccan government made a significant policy change in the early 21st century. It decided to incrementally transition from being a mainly transit migration country into both a transit and destination country for migrants. In 2013, the government implemented the National Strategy on Immigration and Asylum that improved access to public health care for migrants. There are currently one hundred thousand migrants in the country, all of whom have the right to health care.
At the risk of damaging its economy, Morocco acted decisively in the spring of 2020 to contain the pandemic, putting the entire country in lockdown, and cutting off tourism and other travel. Health awareness was prioritized. For example, health care professionals and stakeholders collaborated on a program intended to educate Moroccans about tobacco use and Covid-19.
Human resources shortages, inadequate public spending and urban-rural disparities remain. However, given the problematic disruptions in international trade that led to shortage of raw material to make pharmaceuticals, an effort is underway to strengthen local supply chains.
– Experts agreed that across the MENA region the Covid-19 pandemic has added another problematic layer on top of sectarianism, military occupation, and economic sanctions.
– If healthcare is a priority, democratic values are a precondition for it. Therefore, peaceful conditions must be created for a functional political life in MENA region countries.
– The international community must undertake the hard work of resolving sources of conflict along with local stakeholders. This means ensuring that the security of people (and their food and water) is more highly valued than that of states by reducing military budgets,
– International organizations and NGOs must develop more effective and contextualized programming to address the root causes of regional fragility.
– Coordinated security must be developed to prevent and monitor attacks on healthcare workers. Transitional justice mechanisms in health care should be an essential part of peace keeping initiatives.
– An international conference should be held to find ways to “decolonize the global health system” to create more equity in the health and political spheres by transforming economies and improving political infrastructure.
– To improve health care, significant reforms and policy changes must increasingly consider the inclusion and engagement of women at all levels of public and economic spheres in the MENA region.
– Priority must be given to women’s mental health, antenatal and reproductive services and digital health care and remote interventions must be delivered to women.
– Policymakers must prepare for an increasing percentage of aging people, since the United Nations (2017) estimates that the number of older persons (60+) is expected to more than double by 2050 and to more than triple by 2100.
– Mental health programming should be more directly linked to primary health care.
– Covid-19 challenges MENA region governments to mainstream migrations issues into government policies so that no one is left behind.
Dr. Jubin Goodarzi (Associate Professor and Deputy Head of the International Relations Department at Webster University) thanked all the participants for their contributions and for shedding light on different aspects of delivery and access to healthcare in the MENA region. He stated that the people of the region are facing a multitude of internal and external challenges when it comes to healthcare such as living under authoritarian regimes which do not necessarily ensure equal and equitable access to healthcare and medical resources due to mismanagement and corruption. Furthermore, lack of social development and civil society have perpetuated patriarchy, oppression of women and hindered the ability of women to access healthcare in many parts of the MENA region.
Access to healthcare has been seriously impeded by ongoing conflicts and by outside military interventions —in Libya, Yemen, Syria; occupation in Palestine and the Western Sahara; and economic sanctions against Syria and Iran. The overall situation has deteriorated since the beginning of the century, while the COVID-19 pandemic has exacerbated adverse conditions, resulting in major crises which have brought the healthcare systems in many instances to a breaking point or near collapse.
Nonetheless, local, regional, and international organizations, NGOs and civil society organizations are trying to make a positive contribution to improve healthcare delivery and access for the people of the MENA region. There is no respite on the horizon, and the problems and challenges will persist in the short term and well into the foreseeable future.
Forum participants were requested to provide the MENA Center with further recommendations to advance peace and development. Specifically, they were invited to inform the MENA Center about activities and events that could be organized toward ensuring that healthcare is a public good by collaborating again soon.
A clear sense of common purpose echoed through the Forum on Equal Access to Health Care in the MENA region. The Covid-19 pandemic presents a global opportunity to greatly improve health care in the MENA region in partnership.
While addressing critical and urgent challenges to health care in the MENA region, the thoughtful experts were keen to highlight all the positive factors that have emerged during the Covid-19 pandemic. They expressed both a renewed sense of confidence and a revitalized energy to seek new directions to create improved conditions for peace, justice, and development.
Last but not least, René Schegg, Director for Partnerships and Outreach and a member of the Steering Committee, expressed his great respect for the human rights defenders who spoke at the Forum. He asked them, on behalf of the MENA Center for Peace and Development, how academia could better support civil society and activists in their mutual engagement for more equal access to health care. They responded that real change will only come from a collaboration among these stakeholders. Everyone agreed that the Fora organized by the MENA Center for Peace and Development are very important for more dialogue and change
Prepared by Maryvelma Smith O’Neil, Founder and Co-director, MENA Center for Peace and Development, 9 July 2021.