PUBLIC HEALTH IN THE MIDDLE EAST Reconnaissance of Issues and Developments

PREAMBLE: Over the past 15 years, PacificSci principals have had the opportunity to be involved in aspects of public health development in countries grouped within the Eastern Mediterranean Regional Office of the World Health Organization (WHO/EMRO), specifically Kuwait, Pakistan and the United Arab Emirates (UAE). This has been by virtue of both full time geographically-based work (1998-2003), as well as short term consultancies and collegial links.

These countries and their neighbours in the region face many common and similar challenges in terms of social and economic development, status of women, environmental control and regulation, a highly mobile migrant workforce and other demands of competing in a globalized economy.

Over the past decade especially, the region as a whole has also been dealing with social and political unrest, much of this of an extreme nature, largely resulting from a lack of good governance combined with negative geopolitical dynamics that have given scant regard to the wellbeing of the general populace.

Good public governance, referring to how public institutions function responsively, transparently, and with accountability, is a key mechanism through which the values of development are secured for people. These values include equality of treatment, freedom to choose, opportunities to participate in the process, and not least of all - justice. Such governance recognizes the integrity, rights, and needs of everyone within the state, and is essential to reducing poverty and stimulating growth.[1]

Good governance also embodies the value of “healthy public policy”, characterized by explicit concern for health and equity in all areas of policy and by accountability for health impact. The main aim of health public policy is to create a supportive environment to enable people to lead healthy lives. Such a policy makes health choices possible or easier for citizens. It makes social and physical environments health-enhancing. In the pursuit of healthy public policy, government sectors concerned with agriculture, trade, education, industry, and communications need to take into account health as an essential factor when formulating policy. Healthy public policy benefits populations, communities and individuals.[2]

This brief Reconnaissance consists of two sections: first, the published perspectives of the World Bank and WHO/EMRO, and secondly, our own observations of the emergence of two important networks: public health associations, and membership of national public health institutes in a new global organization.
Note: Minor edits were made to this posting on May 17 and 18, 2012.

PUBLIC HEALTH IN THE MIDDLE EAST
– Regional Perspectives
A DECADE AGO, the World Bank supported a regional conference in Beirut which led to a major report entitled Public Health in the Middle East and North Africa – meeting the challenges of the twenty-first century.[3]

Based on discussion elaborated in chapters of this report, six priorities emerged: 1. Leadership and Political Will 2. A New View of Public Health 3. Data and Surveillance 4. Partnerships and Collaboration 5. Emerging Health Problems 6. Public Health “Best Buys”

The report stated that “the status of public health practitioners is a significant problem. One of the main challenges facing public health in the... region is the recruitment and retention of appropriate skills and expertise, in terms of both quality and quantity.”

The persistence of an outmoded view of public health therefore is part of the challenge in this region, and could be the greatest obstacle to change: a view of public health as an adjunct to the health care system, rather than as a strategic force for a healthy population.

The challenge therefore is to envision what public health throughout the region could become within a reasonable period, say 15-20 years, then determine how to take it there. Insightful leadership with political support can lead this change.

It is on this particular issue regarding outmoded concepts of public health that the following selected extracts from the 2002 World Bank summary of priority issue #2 (above) justify consideration (bullets added and sequence adjusted for emphasis) and are highly applicable to the region:

A New View of Public Health:
• Countries should undertake assessments of their public health functions and capacity in the near future…. steps should be taken to build capacity and broaden the scope of public health beyond the activities of physicians….
• Public health infrastructure should not be an adjunct to curative health systems. Rather it should be part and parcel of a comprehensive health system that blurs the boundaries between curative and public health services.
• There must be greater multisectoral commitment to healthy public policies; this can be accomplished by developing objectives and targets for healthy populations and lifestyles, including the necessary laws and regulations.
• Developing community based health promotion programs can be an effective way to increase the health literacy of communities.

Now moving to a more recent review by World Bank regional specialists [4], disease-surveillance systems as reviewed by the WHO Regional Office WHO/EMRO) were considered mostly inadequate, with insufficient commitment, lack of practical guidelines, overwhelming reporting requirements, lack of transparency, shortage of human resources, and poor analysis of data. It is stated that: “this deficit in the capability to assess and monitor population health will have to be addressed if effective plans for public health capacity building are to be put in place”.

Equally critical, the World Bank reviewers considered that, while many public-health services are well-established, management functions such as inter-sectoral policymaking, public information and education, and quality assurance, are underdeveloped.

Further, when compared with other world regions, the limited interaction between governments and civil society is considered likely to reduce the social dividend by not meeting rising expectations in the population.

The review argued that higher health sector spending will not translate into effective results if investments are not well managed or directed towards cost-effective solutions, and concludes that new institutional capacities and governance structures are needed.

New Public Health Networks
In some countries, there are organized public health professional and lay networks. These are generally found in larger countries, although with varying levels of vitality e.g., national public health associations exist in Egypt, Ethiopia, Iran, Lebanon, Pakistan, Sudan and Yemen. At the other extreme, the Gulf states so far generally lack this type of non-governmental support for public health; these entities typically have much smaller national populations (with the exception of Saudi Arabia with 27.4 million people, of whom some 19 million are nationals).  Such associations have the opportunity to affiliate with a long-standing and reputable international body: the World Federation of Public Health Associations (WFPHA).[5]

Note: The six Arab states bordering the Arabian Gulf: Saudi Arabia, UAE, Qatar, Kuwait, Bahrain and Oman form the Gulf Cooperation Council (GCC). Although Iraq is an Arab state and shares a small border with the Gulf, it is generally not included within this grouping.

Interestingly, national public health institutes are also reaching out among themselves, by affiliating with a recently formed International Association of National Public Health Institutes (IANPHI).[6] Among EMRO countries, these include Afghanistan, Iran, Jordan, Morocco, Pakistan and Saudi Arabia. Turkey and Israel are also members of IANPHI, but not included within the WHO-EMRO group of countries (they are considered within WHO-EURO).

In other words, these governmental public health agencies are starting to link up within an international network. According to their website, IANPHI spearheads improvements in national public health systems through a peer-assistance evaluation, grant support and efforts focused on NPHI advocacy, collaboration, and sustainability. It provides direct funding to governments in low-resource countries to build and strengthen national public health capacity through development of NPHIs. It does this through grants to support NPHI to NPHI evaluations, longer term capacity building initiatives, and seed grants to assist particular research agendas.

All this may make it attractive for other Middle Eastern countries to consider both supporting the development of public health associations and also joining this global intergovernmental agency network, particularly those who need to build capacity... and (when it comes down to it) who doesn't? 

Developing a national public health association, especially, is a  way of strengthening the role of civil society in a domain that can only be in the best interests of the population.

Envoi –Springtime for Public Health in the Middle East?
Prerequisites for health and social development everywhere are peace and justice; nutritious food and clean water; education and decent housing; a useful role in society and an adequate income; conservation of resources and the protection of the ecosystem. These increasingly appear to be the aspirations of Middle Eastern peoples, and indeed throughout the greater Eastern Mediterranean Region.

The vision of healthy public policy is the achievement of these fundamental conditions for healthy living. The achievement of global health rests on recognizing and accepting interdependence both within and between countries. Commitment to global public health will depend on securing the means of international cooperation, especially to act on issues that cross national boundaries.[6]

While the road ahead will have its challenges, and will require new forms of leadership, the international networking that is starting to emerge in the Middle East may well be a forerunner of an “Arab Spring for public health”. If so, this can only be to the ultimate benefit of all who live in the region.

References
1. World Bank. Better Governance for Development in the Middle East and North Africa: Enhancing Inclusiveness and Accountability. 2011. http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/MENAEXT/EXTMNAREGTOPGOVERNANCE/0,,contentMDK:20261216~pagePK:34004173~piPK:34003707~theSitePK:497024,00.html Accessed May 14, 2012.
2. Report on the Adelaide Conference. Healthy Public Policy. 2nd International Conference on Health Promotion April 5-9, 1988 Adelaide South Australia. http://www.who.int/healthpromotion/conferences/previous/adelide/en/index1.html Accessed May 14, 2012.
3. Pierre-Lousie AM, Akala FA, Karam HS. Public health in the Middle East and North Africa: meeting the challenges of the twenty-first century. World Bank Institute. WBI Learning Resources Series. The World Bank 2004.
4. Akala FA, El-Saharty S. [The aWorld Bank, Middle East and North Africa Region, Human Development Sector, Washington, DC] Public-health challenges in the Middle East and North Africa. The Lancet (2006) 367: 961-4.
5. World Federation of Public Health Associations. http://www.wfpha.org/  Accessed May 16, 2012.
6. Public Health Institutes of the World (IANPHI). http://www.ianphi.org/  Accessed May 13, 2012.

FAMILY PLANNING & REPRODUCTIVE HEALTH FALL OFF GLOBAL DEVELOPMENT RADAR

WASHINGTON, June 30, 2009. On the eve of the 20th anniversary of World Population Day, the World Bank and the United Nations Population Fund (UNFPA) warned that family planning and other reproductive health programs vital to poor women had fallen off the development radar of many low-income and donor country governments and international aid agencies.

These programs, they said, were vital to boost women’s economic and social well-being, especially during the current global economic crisis, and to reduce endemic poverty and high numbers of maternal and infant deaths.

”The global economic downturn has taken a wrecking ball to growth and development in poor countries worldwide, and has become a development emergency for women because invariably they’re the first to suffer when economic crises strike”, said Joy Phumaphi, Vice President for Human Development at the World Bank, and a former Health Minister for Botswana. “Even before this crisis began, family planning and reproductive health had fallen off the radar of low-income countries, aid donors, and development agencies with the result that we’ve lost precious time in helping women get access to these vital health services, and helping countries get on a faster track to reducing poverty.”

Delivering a keynote address at the World Bank to mark the 20th anniversary of World Population Day, UNFPA Executive Director Thoraya Obaid said that investing in women was a smart choice during a time of global economic crisis and cutbacks in health budgets worldwide.

“The sad and shocking truth is that maternal mortality represents the largest health inequity in the world, and of all the Millennium Development Goals, MDG 5 to improve maternal health is lagging the farthest behind. And with the financial crisis and the reduction in budgets for health, this goal will be even harder to realize. It is not a lack of knowledge that is hindering progress; it is a lack of political will to protect the health and rights of women.”

New preliminary World Bank figures show that while official global developmentaid for health soared from US $2.9 billion in 1995 to US $14.1 billion in 2007,roughly a five-fold increase in 12 years, aid for population and reproductive health had increased much more modestly during the same period, from $901 million in 1995 to $1.9 billion in 2007. In the 35 highest-fertility countries in Africa, Asia, and the Middle East, aid for women's family planning and reproductive programs started at $150 million in 1995 and increased to $432 million in 2007, while overall aid for health in these 35 countries went from $915 million in 1995 to $4.9 billion in 2007. Support for population and reproductive health programs has significantly declined as a percentage of overall health aid, from about 30 percent in 1994 to 12 percent in 2008.

According to UNFPA, more than 500,000 women die each year during pregnancy and childbirth from mostly preventable and treatable medical problems. For every woman who dies, another 20 women suffer injuries and disabilities that can last a lifetime and rob them of livelihoods and physical well-being. Of all regions, Africa has the world’s highest rates of maternal mortality, at least 100 times those in developed countries.

Also speaking at the World Bank on behalf of the Obama Administration, Margaret Pollack, Acting Deputy Assistant Secretary, Bureau of Population, Refugees, and Migration, U.S. Department of State, said that falling birth rates cannot be achieved through better health programs alone and that better education for girls, equal economic opportunities for women, and fewer households living below the poverty line are also vital.

"We have seen time and time again that investing in women is an investment in families, communities, and societies. It is, in other words, an investment in our future. The United States is engaged and committed, and we look forward to working in partnership to ensure a world in which women are healthy, respected, and their rights are protected."

During the second half of the 20th century, world population more than doubled to reach 6 billion, an astonishing 3 billion increase in population in just 40 years. Although this rate has now slowed to 1.2 percent a year, an additional 75 million people are being added every year this decade. The world’s population could reach up to 9 billion by 2050, with the majority likely to live in the world’s poorest countries.

A recent World Bank report, Population Issues in the 21st Century: The Role of the World Bank, notes that family size can also greatly affect women’s jobs in the workplace. One cross-national survey suggests that the percentage of women in the labor force is directly related to national birth rates. For example, in Bolivia, there were strong links between women using contraception and having jobs outside of the home. In the Philippines, the average income growth for women with 1-3 pregnancies was twice that of women who had been pregnant more than seven times. The globe’s highest birth rates are found in Sub-Saharan Africa, where average fertility remains above five children per woman.

”The low status of women often poses a barrier because in many societies, women lack the power to make their own decisions about using contraceptives or using other reproductive healthcare”, says Joy Phumaphi of the World Bank. “Educating girls, improving economic opportunities for women, while giving them control over the design, management, and oversight of reproductive health programs, are very important ways to encourage better access to these essential health programs.”

Source: Press Release No: 2009/450/HD Washington, June 30, 2009.
For further information: World Bank Contact in Washington: Phil Hay (202) 473-1796 Cell (202) 409 2909 phay@worldbank.org UNFPA Contact in New York: Omar Gharzeddine (212) 297-5028 gharzeddine@unfpa.org

GLOBAL ECONOMIC CRISIS AND THE MILLENNIUM DEVELOPMENT GOALS

PREAMBLE: For this issue we have selected a recent UN News Release that addresses global consequences of the greed and corruption in the financial industry. While almost all people have been affected by the economic crisis, the World Bank states that the crisis is set to drive 53 million more people into poverty in 2009, seriously threatening the prospect of achieving the Millennium Development Goals.

ECONOMIC CRISIS TO DRIVE MILLIONS INTO POVERTY IN 2009
13 February 2009 – The spreading global economic crisis is set to trap up to 53 million more people in poverty in developing countries this year on top of the 130-155 million driven into poverty in 2008 by soaring food and fuel prices, bringing the total of those living on less than $2 a day to over 1.5 billion, according to the World Bank.

The new forecast highlights the serious threat to achieving the United Nation's Millennium Development Goals (MDGs), which aim to slash poverty, hunger, infant and maternal mortality, and lack of access to health care and education, all by 2015. Preliminary estimates for 2009 to 2015 forecast that an average 200,000 to 400,000 more children a year may die if the crisis persists, making a total of 1.4 to 2.8 million over the period.

“The global economic crisis threatens to become a human crisis in many developing countries unless they can take targeted measures to protect vulnerable people in their communities,” World Bank President Robert B. Zoellick said on the eve of the Group of Seven (G7) finance ministers' meeting of leading industrial countries in Rome on Saturday, which he will attend.

“While much of the world is focused on bank rescues and stimulus packages, we should not forget that poor people in developing countries are far more exposed if their economies falter. This is a global crisis requiring a global solution. The needs of poor people in developing countries must be on the table.”

New estimates for 2009 suggest that lower economic growth rates will trap 46 million more people on less than $1.25 a day than was expected prior to the crisis, for a total of an extra 53 million trapped on less than $2 a day, on top of the 1.37 billion before the current crises.

A World Bank policy note issued in the run up to the G7 meeting reports that almost 40 per cent of 107 developing countries were highly exposed to the effects of the crisis and the remainder were moderately exposed, with less than 10 percent facing little risk.

It is critical for exposed countries to finance job creation, delivery of essential services and infrastructure, and safety net programmes for the vulnerable, according to the note, entitled The Global Economic Crisis: Assessing Vulnerability with a Poverty Lens.

Yet three quarters of these countries cannot raise funds domestically or internationally to finance programmes to curb the effects of the downturn. One quarter of them also lack the institutional capacity to expand spending to protect vulnerable groups. The note urges financial support in the form of grants and low or zero interest loans for these countries.

Mr. Zoellick recently called for the establishment of a Vulnerability Fund in which each developed country would devote 0.7 per cent of its stimulus package to aid poorer countries set up safety net programmes, invest in infrastructure, and support small and medium-sized enterprises and microfinance institutions.

Source: UN News Service. http://www.un.org/apps/news/story.asp?NewsID=29897&Cr=financial&Cr1=crisis

WORLD DEVELOPMENT CALLS FOR INVESTMENT IN AGRICULTURE 2008

PREAMBLE: The World Development Report 2008 (reference link below) calls for greater investment in agriculture in developing countries. This annual World Bank report warns that the sector must be placed at the center of the development agenda if goals of halving extreme poverty and hunger by 2015 are to be realized.

o While 75% of the world’s poor live in rural areas in developing countries, a mere 4% of official development assistance goes to agriculture.
o In Sub-Saharan Africa, a region heavily reliant on agriculture for overall growth, public spending for farming is also only 4% of total government spending and the sector is still taxed at relatively high levels.
o GDP growth originating in agriculture is about four times more effective in raising incomes of extremely poor people than GDP growth originating outside the sector.

Said World Bank Group President Robert B. Zoellick: “At the global level, countries must deliver on vital reforms such as cutting distorting subsidies and opening markets, while civil society groups, especially farmer organizations, need more say in setting the agricultural agenda.”

In this issue we focus on Malawi as a Case Study of the role of new subsidies to enhance agricultural production, despite decades of donor proscription not to subsidize, and take note of a World Trade Organization investigation into the use by the United States of truly massive trade-distorting farm subsidies in violation of international commerce rules.

Reference : World Development Report 2008: Agriculture for Development. http://econ.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTRESEARCH/EXTWDRS/EXTWDR2008/0,,contentMDK:21410054~menuPK:3149676~pagePK:64167689~piPK:64167673~theSitePK:2795143,00.html

Case Study - ENDING FAMINE IN MALAWI
After a disastrous corn harvest in 2005, almost 40% of Malawi’s 13 million people needed emergency food aid. Move forward to 2007, and Malawi is selling more corn to the UN’s World Food Programe than any other country in southern Africa. Farmers explain the extraordinary turnaround with one word: fertilizer.

Over the past 20 years, the World Bank and some rich nations Malawi depends on for aid have periodically pressed this small, landlocked country to adhere to free market policies and cut back or eliminate fertilizer subsidies, even as the USA and Europe extensively subsidized their own farmers. But after the 2005 harvest, the worst in a decade, Bingu wa Mutharika, Malawi’s newly elected president, decided to follow what the West practiced, not what it preached, reinstating and deepening fertilizer subsidies.

The country’s successful use of subsidies is contributing to a broader reappraisal of the crucial role of agriculture in alleviating poverty in Africa and the pivotal importance of public investments in the basics of farm economies: fertilizer, improved seed, education, credit and agricultural research. Malawi’s leaders long favored fertilizer subsidies, but reluctantly acceded to donor prescriptions, often shaped by foreign-aid fashions in Washington, that featured faith in private markets and antipathy to public intervention.

In a withering evaluation of the World Bank’s record on African agriculture, the bank’s own internal watchdog concluded in October not only that removal of subsidies had led to exorbitant fertilizer prices in African nations, but that the bank itself often failed to recognize that improving Africa’s declining soil quality was essential to lifting food production.

In Malawi, deep fertilizer subsidies and lesser ones for seed, abetted by good rains, helped farmers produce record-breaking corn harvests in 2006 and 2007. An independent evaluation, financed by the USA and the UK, found that the subsidy program accounted for a large share of this year’s increase in corn production. The harvest also helped the poor by lowering food prices and increasing wages for farm workers.

Malawi’s determination to heavily subsidize fertilizer and the payoff in increased production are beginning to change donor attitudes, say economists who have studied Malawi’s experience. The UK (DFID) contributed $8 million to the subsidy program last year. Bernabé Sánchez, an economist with the agency in Malawi, estimated the extra corn produced because of the $74 million subsidy was worth $120 million to $140 million. The US, which has shipped $147 million worth of American food to Malawi as emergency relief since 2002, but only $53 million to help Malawi grow its own food, has not provided any financial support for the subsidy program, except for helping pay for the evaluation of it. Over the years, the USAID has focused on promoting the role of the private sector in delivering fertilizer and seed, and saw subsidies as undermining that effort. But Alan Eastham, the US ambassador to Malawi, said in a recent interview that the subsidy program had worked “pretty well,” though it displaced some commercial fertilizer sales. And the World Bank now sometimes supports the temporary use of subsidies aimed at the poor and carried out in a way that fosters private markets.

In Malawi, bank officials now support Malawi’s policy, though they criticize the government for not having a strategy to eventually end the subsidies, and... say there is still a lot of room for improvement in how the subsidy is carried out. “The issue is, let’s do a better job of it,” said David Rohrbach, a senior agricultural economist at the bank. Though donors are ambivalent, Malawi’s farmers have embraced the subsidies. And the government moved this year to give its people a more direct hand in their distribution.

Source: Adapted from the article by Celia Dugger. Ending Famine, Simply by Ignoring the Experts. New York Times Dec 2, 2007 http://www.nytimes.com/2007/12/02/world/africa/02malawi.html

WORLD TRADE ORGANIZATION INVESTIGATION INTO US SUBSIDIES
GENEVA (AP) — The WTO has opened an investigation into whether the US was violating international commerce rules that limited subsidies to American farmers, three days after the US Senate approved a $286 billion farm bill. Brazil and Canada, frustrated by US resistance to cutting back on subsidies, asked the WTO to condemn Washgton for exceeding permitted levels of what it called trade-distorting handouts to American producers of crops like corn, cotton, rice, soybean and wheat. The panel is expected to issue a first ruling in 2008. The dispute system often takes years before a final decision is reached, but can force countries to change their legislation or face billions of dollars in retaliatory sanctions. The battle over farm subsidies could become a landmark dispute for the WTO because Brazil’s complaint includes payments for ethanol production. The trade body has largely steered clear of energy issues in its 12-year history.

Source: Bradley S. Klapper. Associated Press. December 18, 2007