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Arab countries have committed to the Sustainable Development Goals (SDGs) with the ultimate goal of “LEAVING NO ONE BEHIND”. Health is at the heart of the SDGs grounded in the value of heath equity.[1] The outbreak of the Coronavirus disease 2019 (COVID-19) underlined the long-existing health inequities in the Arab region. Inequalities in health are clearly an endemic feature in the Arab region despite the progress in health in past decades.[2][3][4][5] This blog builds on Arab countries’ commitments to, and investigates the degree of, progress made in achieving improved health equity in the region. More importantly, this blog discusses the major challenges behind health inequity in the Arab region.

Increasing literature notes the health inequalities among and within, the countries of the region. Two recent publications by Rashad and Shawky [6][7] demonstrate a very unequal distribution of ill-health as compared to the population distribution across the various national administrative locations and wealth quintiles. For example, the relative index of dissimilarity expressed in percent [7][8][13] (rID)[1], –an inequality distributional geographic summary measure, for infant mortality in Egypt, Morocco and Sudan is as high as 11.4 percent, 19.6 percent, and 9.7 percent, respectively, with rural settings being the most affected. Similarly, the concentration index redistribution need [7,8-13] (rCI)[2], –an inequality distributional wealth summary measure, demonstrates severe inequality with a clear economic gradient disfavoring the poor regarding infant mortality in Jordan and Morocco, reaching 11.6 percent for both. Moreover, the health agenda is still unfinished, particularly the improvement in health indicators over time does not guarantee improvement in the inequality distribution and is accompanied by a worsening of such a distribution. For example, the neonatal mortality in Egypt was halved from 30 per 1,000 livebirth in 2005 to 14 per 1,000 livebirths in 2014, however the decline was slow in Rural Upper Egypt and was nearly stagnant in the urban governorates, ending in a nearly tripled geographic inequality from rID% of 4.7 percent to 11.7 percent.[6][7]

Most importantly, the health systems in the region are blamed for being inequitable since their efforts are not equally shared by all population subgroups, with the poorest and the residents of rural administrative areas being the least served. For example, the severity of inequality by administrative areas and wealth measured by rID% and rCI% for inaccessible and unaffordable healthcare exceeds 10 percent in Egypt, Jordan, Morocco and Sudan.[6][7]

This implies that the improvement in health and the healthcare systems’ interventions are not equally shared by the population at large. Systematic differences disfavoring and under-serving the poor and the rural residents move the discourse from health inequality to health inequity. This unfairness is often overlooked in the Arab region and is not at the forefront of priorities. The main reasons are the absence of an equity-framing and equity lens in identifying and addressing health inequalities.

The move in international thinking towards a broader vision for health is not yet fully captured in the Arab region. This raises a legitimate question: “what is the difference between assessing health and healthcare on one side and assessing health equity and healthcare equity on the other side?” The answer to this question needs clarification to highlight the need for measuring inequalities in the distribution of health and healthcare, in addition to the overall national averages.

In a new global thinking, there are two different dimensions for health - health status and equitable distribution of health. Health status is what is captured by the health statistics using the traditional measurement tools (count; ratio; proportion; rate). These traditional tools help in assessing the magnitude of the health-related conditions, expressed as overall national averages that could be disaggregated by age, sex, place of residence or any other sub-population disaggregation. The disaggregation helps in assessing the risk that a population subgroup might be at higher risk than the other subgroup(s). Using these traditional tools allows countries to identify the priority health-related conditions or healthcare systems pitfalls on their territories. These disaggregated statistics are available in many national and international reports, platforms or observatories.

Health inequity refers to the unfair and unjust concentration of ill-health or deprivation from healthcare in population subgroups that are avoidable and preventable.[14] Health inequity is a challenge facing all countries the world over. The problem is that health and healthcare inequities are not measurable, however, inequalities in health and healthcare are measurable and can be conceptualized to be judged as inequities.

Inequalities in health illustrate the systematic differences in health among the various population subgroups. When health inequalities are measured by simple gap measures, whether absolute or relative, many limitations are encountered that do not allow for assessing priorities, monitoring progress over time or comparing population subgroups.[7][8][13] In other words, comparing the various groups using the relative ratio or the absolute difference is intended to measure the risk of being affected, but not the concentration of health and healthcare for specific population subgroups. The difference in concentration is a problem of uneven distribution of ill-health or healthcare as compared to the population random distribution. Such comparison highlights the systematic differences encountered in case of inequalities. Thus, illustrating inequalities in health and healthcare requires measures that allow for comparing distributions rather than measuring risk.

Evidence about the magnitude of such unequal distribution and priority health inequalities are almost non-existent in the Arab region. National health information systems (HIS) are not designed to generate information on distributional health inequalities or their association with the social root causes of ill health. Most evidence on health inequalities are based on household surveys which are only carried by 17 out of 22 countries, and if available lack many health indicators and/or are outdated. Furthermore, countries struggle between the numerous social stratifications including wealth, education, gender, place of residence, nationality, …etc. using very simplistic gap measures which hardly portrait the factual signals.[7][8][13] Until now, there is no consensus on a social stratification and a standard distributional measure –more informative than gap measures, that can be routinely part of the HIS data to alert countries to the inequalities in health and identify priority health inequalities. These limitations coupled with the traditional focus on aggregated averages of health outcomes keep health inequality relatively invisible and public policies unaccountable.

The region’s health systems make use of the available evidence to address the unfinished health agenda but pay little attention to the many health inequity challenges. In particular, the health systems adopt sectoral actions explicitly targeting the priority health conditions that are not always the priority health inequalities.[6][7] They try to respond to the different health needs and even seek partnerships with other social sectors and implement multisectoral initiatives that cater for improving health among the high risk groups which are still not necessarily the vulnerable and underserved.

Most importantly, the health systems still carry the mindset that they are the sole health players and even if they seek partnerships, these are to relieve the burden of ill-health and not the burden of social vulnerabilities. It is true that the health systems are key players and should mainstream a fairness in their policies and interventions, however, this is just one step to achieve equity in healthcare, which is not a proxy for equity in health.[14] Equity in healthcare is a central goal of a robust health system and implies that healthcare resources and services are fairy allocated to the population at large, while equity in health is a central goal of “Whole-of-Government” that is managed within and outside the health systems using intersectoral actions.[14]

Other non-health sectors are key stakeholders and contributors for achieving better health outcomes in the society. Many applied interventions aim to relieve the burden of social vulnerabilities such as the conditional cash transfer program, women empowerment interventions, etc. However, this is not all what is needed. Embracing fairness recognized in the 2030 Agenda requires transformative policies and “Whole of Government” approach integrating an equity lens in all social arrangements and placing “Health in All Policies”. The achievement of health equity requires implementing a policy reform movement that includes articulating health as a whole-of-government responsibility, developing policies and strategies to prevent social vulnerabilities not just relief their burden.

To conclude, it is time for Arab countries to respond to the aspirations of their people and to engage with the current global movement by placing health at the center of development. Without an explicit picture of the distribution of health across the various population subgroups, it is not surprising that awareness and responsibility of ‘‘Whole of Government’’ remain constrained and countries remain silent on whether health inequalities increase, decrease, or remain stagnant and people remain vulnerable and underserved.

It is apparent that the extent of inequality in the distribution of health across the population subgroups is a complimentary key imperative piece of information in a country’s HIS. Furthermore, a “Whole-of-Government” business and “Health in All Policies” approach are the key route to “Leaving-No-On-Behind” and building resilient nation.

Sources:

[1] United Nations. Transforming our world: The 2030 agenda for sustainable development; 2015. A/RES/70/1. Available at:
https://sustainabledevelopment.un.org/post2015/transformingourworld/publication [Accessed 10 August 2020].
[2] Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], and ICF International. 2015. Egypt Demographic and Health Survey 2014. Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International. Available at: https://dhsprogram.com/pubs/pdf/FR302/FR302.pdf [Accessed 10 August 2020].
[3] Department of Statistics (DOS) and ICF. 2019. Jordan Population and Family and Health Survey 2017-18. Amman, Jordan, and Rockville, Maryland, USA: DOS and ICF. Available at:
https://dhsprogram.com/pubs/pdf/FR346/FR346.pdf [Accessed 10 August 2020].
[4] Ministry of Health (Morocco), Pan Arab Project for Family Health (PAPFAM), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA), World Health Organization (WHO). Morocco National Survey on Population and Family Health 2010-2011. Available at: http://ghdx.healthdata.org/record/morocco-national-survey-population-and-family-health-2010-2011 [Accessed 10 August 2020].
[5] Central Bureau of Statistics (CBS), UNICEF Sudan. 2016, Multiple Indicator Cluster Survey 2014 of Sudan, Final Report. Khartoum, Sudan: UNICEF and Central Bureau of Statistics (CBS), February 2016. Available at: https://mics-surveys-prod.s3.amazonaws.com/MICS5/Middle%20East%20and%20North%20Africa/Sudan/2014/Final/Sudan%202014%20MICS_English.pdf [Accessed 10 August 2020].
[6] Rashad, H., S. Shawky, and Z. Khadr. 2019. “Reproductive Health Equity in the Arab Region: Fairness and Social Success” Regional Study; The Social Research Center, The American University in Cairo, UNFPA/ASRO. http://schools.aucegypt.edu/research/src/Documents/SRH-Inequities/Reproductive-Health-Equity-in-the-Arab-Region.pdf [Accessed 10 August 2020].
[7] Sherine Shawky. Measuring Geographic and Wealth Inequalities in Health Distribution as Tools for Identifying Priority Health Inequalities and the Underprivileged Populations. Global Advances in Health and Medicine 2018: Volume 7: 1–10. [Accessed 10 August 2020].
[8] Ontario Agency for Health Protection and Promotion (Public Health Ontario). Summary measures of socioeconomic inequalities in health. Toronto, ON: Queen’s Printer for Ontario; 2013.
[9] Wagstaff A, Paci P, van Doorslaer E. On the measurement of inequalities in health. Soc Sci Med. 1991;33(5):545-57. [Accessed 10 August 2020].
[10] Asada Y. A framework for measuring health inequity. J Epidemiol Community Health 2005;59:700–705. doi: 10.1136/jech.2004.031054. [Accessed 10 August 2020].
[11] Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health 2006;27:167-94. [Accessed 10 August 2020].
[12] Koolman X and van Doorslaer E. On the interpretation of a concentration index of inequality. Health Economics 2004, 13: 649–656. Available at http://onlinelibrary.wiley.com/doi/10.1002/hec.884/epdf [Accessed 10 August 2020].
[13] World Health Organization. Handbook on Health Inequality Monitoring with a special focus on low- and middle-income countries. World Health Organization 2013. [Accessed 10 August 2020].
[14] CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization. Available at: https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf?sequence=1 [Accessed 10 August 2020].