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The Arab Spring: Confronting the challenge of non-communicable disease

Bayard Roberts a, * , Preeti Patel b , Maysoon Dahab c , and Martin McKee d
a Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 1517 Tavistock Place, London WC1H 9SH, UK. E-mail: b c

Department of War Studies, Kings College London, UK.

Public Health Consultant, London, UK.

Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.

*Corresponding author.

Abstract This Commentary considers the health system and policy challenges of addressing non-communicable diseases (NCDs) in Egypt, Libya, and Tunisia, countries in the process of re-framing state policies and institutions, including in the health sector. Against this backdrop, a neglected issue of the rapidly rising burden of NCDs threatens both health and economic development. Tackling this worrisome rise in NCDs has been impeded by inadequate policies. Weak health systems, little attention to determinants of health, and limited access to affordable health care complicate effective responses to NCDs, especially in a fragile transitional phase. There remains an opportunity to confront the neglected challenge of NCDs by substantially strengthening policies and scaling up comprehensive health systems to more effectively address the causes and treatment of NCDs, including mental health, ultimately to improve population health overall. Journal of Public Health Policy (2013) 34, 345352. doi:10.1057/jphp.2013.14; published online 28 March 2013
Keywords: Arab; NCDs; health systems; health policy

The Arab Spring, which began in Tunisia in December 2010, subsequently spreading across North Africa and the Middle East, reflected widespread disillusionment with the existing order. Rulers were seen as out of touch with the aspirations of their people, failing to respond to their basic needs; several have since been swept away in a tide of popular

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uprisings, while others remain vulnerable. This Commentary considers the health system and policy challenges of addressing non-communicable diseases (NCDs) in Egypt, Libya, and Tunisia all of which experienced regime change and are in the process of re-framing state policies and institutions, including in the health sector. The new regimes in Egypt, Libya, and Tunisia must now try and deliver on the demands made by those who put them in power, including for affordable health care and improving health. Yet, this will not be easy. The previous regimes in Egypt and Libya placed a low priority on health, with government spending on health just 6 per cent and 5 per cent, respectively (while in Tunisia it was higher at 11 per cent).1 Moreover, recent years have seen a gradual deterioration in public health-care coverage. In Egypt, this was associated with an increasing role for private health-care providers, causing a substantial burden of out-of-pocket payments to fall on households.1,2 In Libya, health facilities and supplies have also been destroyed by conflict and many health workers have fled abroad.3 Against this backdrop of low levels of health-care coverage and spending, along with continuing conflicts, tensions, and uncertainty, the new systems will also have to fight a battle against the rapidly rising burden of NCDs. We draw attention to NCDs because they not only present the greatest burden of disease in these countries and threaten to be a serious drag on economies and human wellbeing, but they may also be less visible than the immediate threats of conflict. Tackling NCDs requires a multi-sectoral response involving stronger policies that address the causes of NCDs, and more comprehensive health systems to effectively address population health and its determinants.

The Burden of NCDs and Key Risk-factors

NCDs, principally cardiovascular disease, dominate the disease burden in Egypt, Libya, and Tunisia (Table 1), and are projected to increase significantly. The NCD epidemic is driven largely by three major riskfactors, smoking (particularly high among men), physical inactivity, and nutrition, with the latter two contributing to high levels of obesity. The Middle East and North Africa make up one of the fastest growing cigarette markets in the world.4,5 In Egypt, the burden of female obesity is among the highest globally. This seems to be associated with levels of education, both individually and at neighbourhood level, and limited

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Table 1: Data on NCD burden, risk-factors, and policies, by country Egypt Proportional mortality (% of total deaths, all ages)a Non-communicable disease: CVD 39 Cancers 11 Resp. diseases 3 Diabetes 3 Other NCDs 26 Communicable diseases 12 Injuries 6 Libya Tunisia

43 13 4 2 15 12 11

38 16 4 1 12 22 7

Key behavioural & metabolic NCD risk-factors (estimated prevalence %)a Current daily smoking: Men 35.1 45.5 Women 0.5 0.2 Physical inactivity: Men 35.4 Women 53.6 Raised blood pressure: Men 35.5 45.9 Women 34.5 39.1 Obesity: Men 21.4 19.9 Women 44.5 36.4 Raised cholesterol: Men 33.3 33.3 Women 43.7 33.6 Specific operational policy, strategy, action plan for key NCDs & risk-factors?b CVD DK No Cancer Yes DK Resp. disease DK DK Diabetes DK No Unhealthy diet Yes No Insufficient physical activity DK No Tobacco Yes No

56.5 6.8 30 39.1 39 38.1 12.8 31.7 36.6 42.2

Yes Yes Yes No Yes Yes Yes

a Estimates are for 2008. Source: WHO, non-communicable diseases and mental health: b Data from 2010. Source: Global Health Observatory: CVD, cardiovascular disease. DK, dont know (WHO country office response).

opportunities to exercise; wealthier women with lower levels of education seem most at risk.6 The increased urbanisation in many Arab Spring countries also poses additional risks for NCDs, with evidence from

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Egypt highlighting high tobacco and high fat food consumption in the growing urban slums.7 In addition, there are serious concerns about mental health, given the history of authoritarian regimes, human rights abuses, impoverishment, and the recent violence that could result in significantly elevated levels of post-traumatic stress disorder and common mental disorders such as depression and anxiety.810 Trauma and mental disorders have also been linked with increased risk of substance use, including smoking.11 Concerns have also been expressed about outdated mental health policies, high levels of mental health stigma, and limited availability of appropriate mental health-care workers, services, and resources particularly for treating key disorders such a post-traumatic stress disorder and depression.8,10

Health Policy and System Challenges

Strong policies are required to tackle the rising tide of NCDs in the Arab Spring countries, and health systems need to be scaled-up to address more comprehensively population health and its determinants. However, despite the growing numbers already afflicted by NCDs and in need of care, there has been limited attention by policymakers to NCDs and their risk-factors, with few policies on: providing counselling and multidrug therapy for cardiovascular disease and diabetes; the early screening and timely treatment of cancers; and tackling tobacco use, unhealthy diet, and physical inactivity (Table 1). Currently only Tunisia is reported to have an operational policy for cardiovascular diseases. The extent of implementation of policies to tackle diabetes and hypertension appears very limited in Egypt and Libya. These countries also have no or limited policies to tackle obesity and physical inactivity. This is compounded by heavy reliance on oil exports and limited domestic food production so that Arab Spring countries are net-food importers, something that increases risk of consumption of imported processed foods with high fat and salt content.12 Multi-sectoral policies are required to address the determinants of NCDs at the micro, meso, and macro levels. Tobacco control is also weak, with aggressive marketing, a lack of smoking bans, and inadequate cigarette packet labelling helping to explain the rapid rises in smoking in the region.5 Analysts also observe that the competing pressures on new governments may weaken efforts to enforce the existing tobacco control measures and tackle the illicit tobacco

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trade, already widespread in the region.4 This could be compounded by new governments seeking to privatise state tobacco companies as a means of releasing capital and increasing foreign investment, with encouragement from international financial institutions.13 However, this privatisation risks increasing cigarette consumption, lowering the age of smoking initiation, and weakening tobacco control measures.14 Closer adherence is essential to the key tobacco control measures outlined in the Framework Convention for Tobacco Control, to which all three countries are signatories. Not only smoking but workplace and environmental exposures likely to rise with increased industrialisation contribute to the burden of chronic pulmonary disease, cancer, and other NCDs. In Egypt, for example, silica dust exposures in mines and ceramic factories and cotton dust in textile workplaces combine with tobacco effects to advance lung and other chronic diseases.15 Strong health systems are required to address NCD prevention, treatment, and management effectively. A continuation of the increasingly fragmented and privatised health-care services will make it even more difficult to develop a comprehensive and effective approach to tackling NCDs. This will also pose challenges to measures aimed at reversing the growing health inequalities and the failures of previous governments to meaningfully engage with the social determinants of health.2,16 Public provision of health care must be strengthened to reduce the barriers for those seeking care for NCDs, particularly for the poor, women, and those living in rural areas.2 This includes scaling up evidence-based packages of mental health care, particularly at the primary health level, to improve the prevention and management of mental disorders.17 Importantly, health systems should be understood not just as the services, staff, resources, equipment, and products to treat individuals but also the activities to prevent ill health, to address health risk-factors and inequalities, and to measure population health and its determinants.18,19 This requires a strengthening of public health monitoring and surveillance systems to collect data on NCD prevalence and key risk-factors. It should also be accompanied by in-depth research to examine health policy and systems issues. Similarly, comprehensive health systems should address the activities of sectors impacting upon population health, such as industry, trade, and finance, in order to better address NCD risk-factors such as tobacco and obesity with the ultimate goal of improving population health outcomes.

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There have already been attempts by the new regimes to develop and implement health-care reform policies, such as proposed plans in Egypt to provide primary health care in rural areas, free medical treatment in hospitals, and subsidized treatment of children under six who are not covered by health insurance, plus regulation of private health-care providers. In Libya, the National Health Systems Conference held in Tripoli in August 2012 addressed the challenges facing the countrys collapsed health system, including encouraging health professionals to remain in Libya and stay working within the national health system. There are similar attempts in Tunisia to address the low salaries of health workers that previously prompted many young physicians to leave the public sector for private practice. Clearly, the challenges of increasing the resources required for scaling up equitable access to health care are considerable given the limited tax base, the large informal economies where sizeable proportions of labour markets are not covered by insurance or pensions, and regulation and enforcement are weak. There is also the clear danger that the on-going political and economic instability, compounded by governance challenges inherited from the previous regimes, will impede genuinely comprehensive health system reforms.20 The Arab Spring countries might build on experiences from other transitional settings, such as Eastern Europe and the former Soviet Union after the collapse of Communism.21,22 These experiences have highlighted just how difficult it can be to improve access to health care, but also that it is possible. Evidence highlights the importance of strong political leadership, good governance, civil society participation, and a focus on strengthening institutions, all of which help to create a vision for comprehensive health policy and system reform that takes advantage of windows of opportunity.

There is evidently great uncertainty about how the Arab Spring will develop. Tackling NCDs and health system strengthening in a fragile transitional phase when political and social tensions continue and new institutions need to be established is a major challenge. However, there is an opportunity for the new governments to strengthen policies substantially and to scale-up genuinely comprehensive health systems to tackle NCDs, including mental health, more effectively. This will surely improve the lot of their peoples.

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About the Authors

Bayard Roberts, PhD, is Senior Lecturer in Health Systems and Policy at the London School of Hygiene and Tropical Medicine. His research focuses on health systems and policies and health determinants in transitional settings, including those emerging from armed conflict, with a particular interest in non-communicable disease and mental health. Preeti Patel, PhD, is Lecturer in Global Health and Security at the Department of War Studies at Kings College London. Her research areas include: health in conflict-affected countries with a particular interest in health systems, security, governance; globalisation and health; tracking Official Development Assistance for health; and the causes of armed conflict. Maysoon Dahab, PhD, is an epidemiologist and public health consultant, with a special interest in the health of populations in transition. Her current work with UNHCR focuses on studying the health of refugees living in both urban and camp-based settings. Previously she has worked with WHOs Regional office for the Eastern Mediterranean, the World Bank, universities and NGOs on health sector reform, policy guidance, and investigating both chronic and infectious diseases. Martin McKee, CBE MD, is Professor of European Public Health at the London School of Hygiene and Tropical Medicine. He has a strong interest in the health of societies undergoing major transitions, particularly in central and eastern Europe and the former Soviet Union. He has been involved in a number of studies of global reach with publications examining health outcomes, policies and systems in China, Ethiopia, Bangladesh, India, Thailand, and the Arab Spring countries.

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