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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, 15–17 Tavistock Place, London WC1H 9SH, UK. E-mail: Bayard.firstname.lastname@example.org b c
Department of War Studies, King’s College London, UK.
Public Health Consultant, London, UK.
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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, 345–352. 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
r 2013 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 34, 2, 345–352 www.palgrave-journals.com/jphp/
health facilities and supplies have also been destroyed by conflict and many health workers have fled abroad. the new systems will also have to fight a battle against the rapidly rising burden of NCDs. tensions. Libya.The Arab Spring uprisings. The NCD epidemic is driven largely by three major riskfactors. causing a substantial burden of out-of-pocket payments to fall on households. both individually and at neighbourhood level. Libya.5 In Egypt. Libya. principally cardiovascular disease.1 Moreover. while others remain vulnerable. 0197-5897 Journal of Public Health Policy Vol. The Burden of NCDs and Key Risk-factors NCDs. and uncertainty. and Tunisia all of which experienced regime change and are in the process of re-framing state policies and institutions. this was associated with an increasing role for private health-care providers. and more comprehensive health systems to effectively address population health and its determinants. dominate the disease burden in Egypt. 2. 34. and are projected to increase significantly. including for affordable health care and improving health. with government spending on health just 6 per cent and 5 per cent. and nutrition.4. but they may also be less visible than the immediate threats of conflict. including in the health sector. and Tunisia (Table 1). This seems to be associated with levels of education. 345–352 .2 In Libya. respectively (while in Tunisia it was higher at 11 per cent). The new regimes in Egypt. This Commentary considers the health system and policy challenges of addressing non-communicable diseases (NCDs) in Egypt.3 Against this backdrop of low levels of health-care coverage and spending. along with continuing conflicts. 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. In Egypt. and Tunisia must now try and deliver on the demands made by those who put them in power. smoking (particularly high among men).1. Tackling NCDs requires a multi-sectoral response involving stronger policies that address the causes of NCDs. The previous regimes in Egypt and Libya placed a low priority on health. physical inactivity. recent years have seen a gradual deterioration in public health-care coverage. and limited 346 r 2013 Macmillan Publishers Ltd. Yet. The Middle East and North Africa make up one of the fastest growing cigarette markets in the world. this will not be easy. with the latter two contributing to high levels of obesity. the burden of female obesity is among the highest globally.
who. 0197-5897 Journal of Public Health Policy Vol.9 Women 34.1 Obesity: Men 21.6 42.1 45.9 Women 44. non-communicable diseases and mental health: www.5 36.5 45.who.7 36. don’t know (WHO country office response). Source: Global Health Observatory: www. wealthier women with lower levels of education seem most at risk. 345–352 347 . all ages)a Non-communicable disease: CVD 39 Cancers 11 Resp. cardiovascular disease.apps. opportunities to exercise. by country Egypt Proportional mortality (% of total deaths.8 30 39. and policies.5 6. 2. 34.1 12.6 Raised blood pressure: Men 35.2 Yes Yes Yes No Yes Yes Yes a Estimates are for 2008.1 39 38. action plan for key NCDs & risk-factors?b CVD DK No Cancer Yes DK Resp.int/ghodata/. with evidence from r 2013 Macmillan Publishers Ltd. strategy.5 0. risk-factors. Source: WHO.6 Specific operational policy.4 Women — 53. DK. CVD. b Data from 2010. 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. disease DK DK Diabetes DK No Unhealthy diet Yes No Insufficient physical activity DK No Tobacco Yes No 56.7 33.4 Raised cholesterol: Men 33.2 Physical inactivity: Men — 35.int/nmh/countries/.3 33.Roberts et al Table 1: Data on NCD burden.5 39.3 Women 43.8 31.5 Women 0.4 19.6 The increased urbanisation in many Arab Spring countries also poses additional risks for NCDs.
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. given the history of authoritarian regimes.8.The Arab Spring Egypt highlighting high tobacco and high fat food consumption in the growing urban slums. and macro levels. The extent of implementation of policies to tackle diabetes and hypertension appears very limited in Egypt and Libya. there has been limited attention by policymakers to NCDs and their risk-factors.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. and physical inactivity (Table 1). 34. meso.11 Concerns have also been expressed about outdated mental health policies. Tobacco control is also weak. These countries also have no or limited policies to tackle obesity and physical inactivity. with few policies on: providing counselling and multidrug therapy for cardiovascular disease and diabetes. services. Currently only Tunisia is reported to have an operational policy for cardiovascular diseases. high levels of mental health stigma. impoverishment.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 348 r 2013 Macmillan Publishers Ltd. with aggressive marketing. despite the growing numbers already afflicted by NCDs and in need of care. something that increases risk of consumption of imported processed foods with high fat and salt content. 2. and limited availability of appropriate mental health-care workers.7 In addition. 345–352 . This is compounded by heavy reliance on oil exports and limited domestic food production so that Arab Spring countries are net-food importers. 0197-5897 Journal of Public Health Policy Vol. human rights abuses.8–10 Trauma and mental disorders have also been linked with increased risk of substance use. and resources – particularly for treating key disorders such a post-traumatic stress disorder and depression.12 Multi-sectoral policies are required to address the determinants of NCDs at the micro. and tackling tobacco use. and inadequate cigarette packet labelling helping to explain the rapid rises in smoking in the region. the early screening and timely treatment of cancers. unhealthy diet. a lack of smoking bans. including smoking. However. there are serious concerns about mental health.
and products to treat individuals but also the activities to prevent ill health. to which all three countries are signatories. cancer. women.18. in order to better address NCD risk-factors such as tobacco and obesity with the ultimate goal of improving population health outcomes. already widespread in the region. particularly for the poor. particularly at the primary health level. resources. r 2013 Macmillan Publishers Ltd. lowering the age of smoking initiation. and weakening tobacco control measures. equipment. comprehensive health systems should address the activities of sectors impacting upon population health. and those living in rural areas.4 This could be compounded by new governments seeking to privatise state tobacco companies as a means of releasing capital and increasing foreign investment. and management effectively.2. with encouragement from international financial institutions. to improve the prevention and management of mental disorders. for example. In Egypt. staff.19 This requires a strengthening of public health monitoring and surveillance systems to collect data on NCD prevalence and key risk-factors. 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. 2. 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. and finance.Roberts et al trade.13 However. this privatisation risks increasing cigarette consumption.16 Public provision of health care must be strengthened to reduce the barriers for those seeking care for NCDs. It should also be accompanied by in-depth research to examine health policy and systems issues. and other NCDs.2 This includes scaling up evidence-based packages of mental health care. 34. trade. treatment. to address health risk-factors and inequalities. Similarly.14 Closer adherence is essential to the key tobacco control measures outlined in the Framework Convention for Tobacco Control. Not only smoking but workplace and environmental exposures – likely to rise with increased industrialisation – contribute to the burden of chronic pulmonary disease.17 Importantly. and to measure population health and its determinants. 345–352 349 . 0197-5897 Journal of Public Health Policy Vol. such as industry.15 Strong health systems are required to address NCD prevention. health systems should be understood not just as the services. 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.
345–352 . good governance. the National Health Systems Conference held in Tripoli in August 2012 addressed the challenges facing the country’s collapsed health system.21.22 These experiences have highlighted just how difficult it can be to improve access to health care. such as proposed plans in Egypt to provide primary health care in rural areas. and regulation and enforcement are weak.The Arab Spring There have already been attempts by the new regimes to develop and implement health-care reform policies. including mental health. including encouraging health professionals to remain in Libya and stay working within the national health system. such as Eastern Europe and the former Soviet Union after the collapse of Communism. will impede genuinely comprehensive health system reforms. Conclusions There is evidently great uncertainty about how the Arab Spring will develop. 2. more effectively.20 The Arab Spring countries might build on experiences from other transitional settings. the large informal economies where sizeable proportions of labour markets are not covered by insurance or pensions. there is an opportunity for the new governments to strengthen policies substantially and to scale-up genuinely comprehensive health systems to tackle NCDs. but also that it is possible. Evidence highlights the importance of strong political leadership. However. 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. 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. 0197-5897 Journal of Public Health Policy Vol. Clearly. free medical treatment in hospitals. compounded by governance challenges inherited from the previous regimes. civil society participation. all of which help to create a vision for comprehensive health policy and system reform that takes advantage of windows of opportunity. 350 r 2013 Macmillan Publishers Ltd. There is also the clear danger that the on-going political and economic instability. 34. This will surely improve the lot of their peoples. plus regulation of private health-care providers. In Libya. and subsidized treatment of children under six who are not covered by health insurance. and a focus on strengthening institutions. the challenges of increasing the resources required for scaling up equitable access to health care are considerable given the limited tax base.
345–352 351 . universities and NGOs on health sector reform. Preeti Patel. Martin McKee. Maysoon Dahab. policy guidance. His research focuses on health systems and policies and health determinants in transitional settings. security. Switzerland: World Health Organisation. and Khawaja. particularly in central and eastern Europe and the former Soviet Union. 0197-5897 Journal of Public Health Policy Vol. (2011) WHO Global Health Expenditure Atlas.Roberts et al About the Authors Bayard Roberts. Zarocostas. r 2013 Macmillan Publishers Ltd. 2. the World Bank. Jabbour. He has been involved in a number of studies of global reach with publications examining health outcomes. with a special interest in the health of populations in transition. Bangladesh. British Medical Journal 343: d4326. Ethiopia.’ says UN. 2. Cambridge. UK: Cambridge University Press. globalisation and health. is an epidemiologist and public health consultant. Her research areas include: health in conflict-affected countries with a particular interest in health systems. R. Geneva. policies and systems in China. (eds. M. including those emerging from armed conflict. tracking Official Development Assistance for health. and the causes of armed conflict. Thailand. 34. governance.. PhD. References 1. WHO. 3. Previously she has worked with WHO’s Regional office for the Eastern Mediterranean. is Professor of European Public Health at the London School of Hygiene and Tropical Medicine. (2011) Libyan health system is ‘absolutely stretched. PhD. and the Arab Spring countries. with a particular interest in non-communicable disease and mental health. Her current work with UNHCR focuses on studying the health of refugees living in both urban and camp-based settings. India. S. He has a strong interest in the health of societies undergoing major transitions. is Senior Lecturer in Health Systems and Policy at the London School of Hygiene and Tropical Medicine. J. is Lecturer in Global Health and Security at the Department of War Studies at King’s College London. PhD. CBE MD. Giacaman. and investigating both chronic and infectious diseases.) (2012) Public Health in the Arab World.
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