www.thelancet.com Vol 383 January 25, 2014
Health in the Arab world: a view from within 3
The path towards universal health coverage in the Arab
uprising countries Tunisia, Egypt, Libya, and Yemen
Shadi S Saleh, Mohamad S Alameddine, Nabil M Natafgi, Awad Mataria, Belgacem Sabri, Jamal Nasher, Moez Zeiton, Shaimaa Ahmad,
The constitutions of many countries in the Arab world clearly highlight the role of governments in guaranteeing
provision of health care as a right for all citizens. However, citizens still have inequitable health-care systems. One
component of such inequity relates to restricted fi nancial access to health-care services. The recent uprisings in the
Arab world, commonly referred to as the Arab spring, created a sociopolitical momentum that should be used to
achieve universal health coverage (UHC). At present, many countries of the Arab spring are considering health
coverage as a priority in dialogues for new constitutions and national policy agendas. UHC is also the focus of
advocacy campaigns of a number of non-governmental organisations and media outlets. As part of the health in the
Arab world Series in The Lancet, this report has three overarching objectives. First, we present selected experiences of
other countries that had similar social and political changes, and how these events aff ected their path towards UHC.
Second, we present a brief overview of the development of health-care systems in the Arab world with regard to
health-care coverage and fi nancing, with a focus on Egypt, Libya, Tunisia, and Yemen. Third, we aim to integrate
historical lessons with present contexts in a roadmap for action that addresses the challenges and opportunities for
progression towards UHC.
Attainment of the best possible health is a human right,
and is part of WHO’s constitution.1 Additionally, the
constitutions of many countries in the Arab world show
the role of government in guaranteeing provision of
health as a right for all citizens. However, many countries
have inequitable health-care systems, contributing to the
poor wellbeing of their citizens. A component of such
inequity is restricted fi nancial access to health-care
services, as manifested by fairly high levels of out-of-
pocket spending on health care. This inequity is further
shown by the millions of people, especially those in low-
income and middle-income countries, who face catas-
trophic spending or fall into poverty after sickness.2–5
Many reasons have been suggested for the recent
uprisings in the Arab world (often referred to as the Arab
spring or Arab uprisings), including high unemployment,
corruption, major abuses of human rights, and—most
importantly with regard to pro gression towards uni versal
health coverage (UHC)—lack of equitable social provision.
In this report in the Series, we focus on four countries in
the Arab world that have had uprisings: Egypt, Libya,
Tunisia, and Yemen (fi gure 1). Although uprisings are also
occurring in other countries in the region at the time of
writing, these four were selected for two main reasons.
First, all had new governments instituted, albeit with
varying functional structures because of the nature of the
transitional phase. Second, the four countries represent
the diversity of the region with regard to wealth,
health-system characteristics (eg, fi nancial protection
portfolios), and social context (tables 1, 2), yet share the
common theme of longstanding regimes that contri buted
to inequity (appendix). The sociopolitical contexts of these
four countries, perhaps because of the early stage of their
revolutions, are far from stabilising. For example, large
public demon strations in the summer of 2013 in Egypt
against its elected President Mohammad Morsi were
followed by a military intervention that overthrew Morsi
and instituted a transitional govern ment. We argue that,
despite the obvious dynamism in the contexts of these four
countries, the Arab uprisings still present an important
socio political enabler for pro gression towards UHC. We
base this argument on the premise that revolutions in
recent history—mostly after World War 1—although vary-
ing widely in terms of genesis, duration, and motivat ing
ideology, have often embraced major changes in eco nomic
policies and governmental role in the provision of social
pro grammes, including those related to health care.
An essential enabler for the successful integration of
more equitable and comprehensive health policies is the
early endorsement of a clear roadmap for progression
towards UHC as health-care systems are modernised,
restructured, or re-engineered.
Lancet 2014; 383: 368–81
January 20, 2014
See Comment page 283
The is the third in a Series of
fi ve papers about health in the
Department of Health
Management and Policy,
American University of Beirut,
Beirut, Lebanon (S S Saleh PhD,
M S Alameddine PhD,
N M Natafgi MPH); WHO
Regional Offi ce for the Eastern
Mediterranean, Cairo, Egypt
(A Mataria PhD, S Siddiqi MD);
Department of Planning and
Development, Ministry of Public
Health and Population, Sana’a,
Yemen (J Nasher MD MSc); Tunis,
Tunisia (B Sabri MD); Sadeq
Institute, Tripoli, Libya
(M Zeiton MRCS); and Offi ce of
the Minister of Health, Cairo,
Egypt (S Ahmed MBA)*
*Dr Ahmed no longer works for
the Offi ce of the Minister of
Dr Shadi S Saleh, American
University of Beirut, Beirut,
See Online for appendix
Figure 1: A map showing Egypt, Libya, Tunisia, and Yemen
www.thelancet.com Vol 383 January 25, 2014 369
In this Series paper we have three complementary
objectives. First, we aim to present selected historical
experiences of countries that had substantial social and
political changes, and how these changes aff ected their
path towards UHC. Second, we present a brief historical
overview of three distinctive phases in the develop ment of
health-care systems (specifi cally fi nancing) in four coun-
tries of the Arab spring, from political independence (early
and mid-20th century) until the onset of uprisings in 2011,
with a focus on the sociopolitical factors that shaped this
development. Lastly, we aim to integrate historical lessons
with present contexts into a roadmap for action that
addresses the challenges and opportunities for pro gression
towards UHC. To address these objectives, enhance
methodo logical rigour, and increase the validity of reported
analyses and con clusions, we use a combination of a
review of literature about historical experiences of coun-
tries that underwent substantial social and political
changes and how these aff ected the path towards UHC,
and an assessment of the structure, processes, and out-
comes (or indicators) of the health-care systems in the
four coun tries. This analysis is supplemented by expert
Yemen Egypt TunisiaLibya YemenEgypt TunisiaLibya
Total per-person expenditure on health (US$)
Government per-person expenditure on health (US$)
Total expenditure on health as a proportion of GDP
Government expenditure on health as a proportion of total health expenditure
Out-of-pocket expenditure on health as a proportion of total health expenditure
Government expenditure on health as a proportion of total government expenditure
Ministry of health budget as a proportion of government budget
Data from the WHO Regional Offi ce for the Eastern Mediterranean.6,7 GDP=gross domestic product.
Table 2: Selected key indicators for health expenditure for Egypt, Tunisia, Libya, and Yemen
Yemen Egypt TunisiaLibyaYemen Egypt TunisiaLibya
Key socioeconomic indicators
Population size (millions)
GDP per capita (US$)
Population younger than 15 years
Literacy rate in people aged 15 years and older
Gross primary school enrolment ratio†
Gross secondary school enrolment ratio total†
Poverty headcount ratio at national poverty line (% of population)*
Gini index (rank)‡
Key health services indicators
Proportion of population with access to local health services
Proportion of 1-year-old infants immunised in 2010
Diphtheria, pertussis, and tetanus vaccine
Oral polio vaccine
Hepatitis B vaccine
Key health outcome indicators
Life expectancy at birth (years)
Infant mortality rate (per 1000 livebirths)
Maternal mortality ratio (per 100 000 livebirths)§
50%100%95%100% 50%100% 95%100%
Data from the WHO Regional Offi ce for the Eastern Mediterranean,6,7 unless otherwise stated. GDP=gross domestic product. *Data from the World Bank.8 †Gross primary and secondary school enrolment ratios
measure the proportion of children enrolled in primary or secondary education (respectively), regardless of age; these measures can exceed 100% because of the counting of overaged and underaged students.
‡Gini index9 represents the score for the most recent year released by the World Bank; ranking based on ascending order of Gini index. §Data from Hogan and colleagues.10
Table 1: Selected key socioeconomic and health indicators for Egypt, Tunisia, Libya, and Yemen
www.thelancet.com Vol 383 January 25, 2014
opinions from key stakeholders in the health systems of
each of the four countries and from regional health
systems. The roadmap towards UHC combines an
analytical synthesis of literature with the contextualised
opinion of health-system stakeholders.
Historical examples of sociopolitical
transformations and developments in
The transformation of health-care systems from inequality
to equality has been argued to be a natural outcome (or
an underlying predecessor) of political transformations
driven by social-equity agendas (fi gure 2). This dynamic
between social equity and UHC was described in the
2008 WHO World Health Report,13 which explicitly stated
that “demand from the communities that bear the burden
of existing inequities and other concerned groups in civil
society are among the most powerful motors driving
universal health coverage reforms”. Evidence from the
scientifi c literature further substantiates this argument by
suggesting that revolutions driven by such an agenda form
a solid path to a more equitable and healthier society.14–22
For example, several movements in European countries
placed pres sure on political leadership to move forward
with health-system reform. Germany is often thought of as
the source of social health insurance because it was the
fi rst European country to enact mandatory state-supervised
legislation, in the Bismarck era of the late 19th century, in
an attempt to contain social unrest in German workers
during the industrial revolution.23 Likewise, in postwar
France, strike waves and mass demonstrations shaped
sociopolitical changes and substantially aff ected the
development of social benefi ts.24 The German and French
scenarios also hold true for reforms after World War 2 in
several western European countries.25,26
Latin America provides additional examples of progress
towards UHC resulting from governments’ response
to organised demands for public health policies. The
demands for public health were a main pillar of oppo sition
movements to military dictatorships in countries such as
Argentina, Brazil, and Chile. For example, the health for all
vision in Brazil emerged during the years of political
opposition and at the end of the military dictatorship that
started in 1964.27 The reform of the Brazilian health sector,
at the same time as democratisation, was driven by civil
society rather than by governments, political parties, or
international organisations.28 Further more, the Cuban
revolution was linked with the nation’s health-care
system.29,30 In fact, Cuba remained faithful to the basic
premises of its system and has been praised by many
for social equity and health outcomes.31–34 After the
1959 revolution, Cuba succeeded in attaining considerable
advances for many health outcomes.35,36
The Middle East is not an exception to this trend of
sociopolitical transformations associated with notable
reforms of health-care systems. For instance, the Turkish
military coup of 1960 was an important turning point in
Turkey’s history, paving the way for major reconstruction
of the constitution of the republic. This major event was
complemented with substantial developments in Turkish
health care with the introduction of the Law on the
Nationalization of Health Care Delivery (Law Number 224)
Figure 2: Global overview of countries with universal health coverage
Based on data for health coverage from Stuckler and colleagues11 and Garrett and colleagues.12
Countries with universal health coverage
Countries with no universal health coverage
www.thelancet.com Vol 383 January 25, 2014 371
and the Law on Population Planning (Law Number 554).37
These laws acknowledged that health-care services should
be delivered equitably, continuously, and in accordance
with the population’s priorities. They were soon followed
by an attempt to establish a national health service with
the endorsement of the 1961 Law on the Nationalization
of Health Care Delivery, with a vision to provide free (or
partly free) health care subsidised by contributions from
citizens and allocations from the government budget
(tax revenue).37,38 In 2003, the Turkish health-care system
under went its most profound change with the implemen-
tation of the Health Transformation Program. As part of
the Health Transformation Program, the Social Security
Institution became the sole payer of health care, and in
case of defi cits, with contributions from employers,
employees, and the government.39 Health policy and
health-care coverage was one of the main platforms that
propelled the present Turkish Government, led by the
Justice and Development party, into power in two
consecutive elections (2007 and 2011). The Health
Transformation Program showed favourable health
outcomes for the population since its inception.37,38
Although many of the substantial health-care reforms
were products of major sociopolitical changes, some
systems underwent reforms as a result of social pressure
and political will and vision. For instance, Mexico
achieved UHC by establishing the System of Social
Protection in Health to provide coverage for its 11 million
uninsured families by 2010.40–42 The political pillar of the
reform for the Mexican health-care system was wide
public participation and involvement of empowered
citizens, in addition to a government administration with
a will for reform.40 Such a model was also observed in
southeast Asia, where governments sought to implement
health-system reforms backed by social support for UHC
implementation.43–46 However, these global examples of
sociopolitical transformations and associated health-
system transformations did not occur in many countries
in the Arab world that underwent similar sociopolitical
changes in the 20th century.
Economic and political context of health-care
An interrupted path towards UHC
The four countries examined in this report have diverse
political, economic, and health profi les (tables 1, 2), but
share a similar chronological and contextual pattern of
change and development of their health-care systems.
Evolution in health-care systems is strongly aff ected by
social, political, and economic factors that shape govern-
ment public policy, including that for health care.
The Arab world endured centuries of non-self-
governance that started with the rule of the Ottoman
Empire and was followed by that of European colonial
powers (ie, France, Italy, Spain, and the UK) after
World War 1. A strong movement for Arab independence
started to emerge in the late 19th and early 20th centuries,
initially supported by western powers to undermine the
hold of the Ottoman Empire on the Arab world. This
movement eventually resulted in most Arab countries
gaining independence from colonialism in the mid-20th
Phase 1: health-care systems in the era of post-
The modern political history of Egypt, Libya, Tunisia, and
Yemen, as for most countries in the Arab world, can
be traced back to the 1950s and 1960s when ruling
monarchies were toppled by military coups in most
countries. The resulting states were labelled republics,
with mostly military leaders assuming power. Pan-Arab
nationalism gained popularity, especially with the
leadership of Gamal Abdul Nasser of Egypt and his active
attempts to achieve Arab unity. During that period, the
ramifi cations of the Cold War resulted in both the east
camp (led by the Soviet Union) and the west camp (led by
the USA) manoeuvring for strategic alliances with
countries and regions around the world. Partly aff ected
by the appeal of socialism (a basis for the revolutions
against monarchies), several Arab countries sided with
the east camp. As a result, strong economic, political,
and military ties were established between the Soviet
Union and Egypt, Yemen (before and after its unifi cation),
and Libya,47–49 along with other countries in the Arab
world. In Tunisia, socialism was even more pronounced,
because the ruling party in the post-revolution era until
the late 1980s was the Socialist Destourian Party.50
Socioeconomic development in the Arab world, includ-
ing that in the health sector, during this era was mostly led
by the state. The socialist approach of the ruling regimes
and parties was translated into movement towards a
welfare state, with health care as an integral component.
All four countries legislated for free access to health care in
their new constitutions. The notion of free access to health
care needed the development of new state fi nancing
structures, or absorbing of existing private systems into
the public sector.51 The health-care systems of the four
countries, as for others in the Arab world, resulted from a
merging of the functions of fi nancing, delivery, and
organisation of health services under state control.52
However, although the evolution into welfare states
provided many citizens with free access to health and other
social services, serious concerns were expressed with
regard to the fi nancial sustainability of the free health-care
policy. Financing of health services by the social security
systems led to budget defi cits in several instances, and
resulted in many health-care facilities lacking necessary
supplies and medications.53–55 Additionally, physicians and
other providers in countries such as Yemen and Egypt
were poorly paid, which created demotivation and
ultimately contributed to poor care in public facilities.52
Another issue was concerns with the overuse of health
services because of free access policies.56 Of the four
countries, Yemen was perhaps the most disadvantaged
www.thelancet.com Vol 383 January 25, 2014
during this phase, with persistent armed confl icts between
the government and tribal groups that led to further
deterioration in the social services infrastructure, placing
the country at the bottom of the human development
ranking among all other Arab countries.57,58
Phase 2: the era of privatisation and cost recovery
In the late 1980s, as a result of challenges in sustaining
of fi nancing and quality of services for free access to
health care, the governments of Egypt, Libya, Tunisia,
and Yemen looked for alternative ways to supplement
the public fi nancing of health. This period coincided
with an increased interest of international funding
agencies, mostly the World Bank and the International
Monetary Fund, in expanding of their investment
portfolios into social development projects. This shift
for investment beyond classic projects for economic
growth (eg, trans portation and energy) was encouraged
by development theories that by the 1980s advocated the
importance of meeting individuals’ basic needs (eg,
health, nutrition, and education).59–61 The shift was
accom panied by an emphasis on issues such as
privatisation and role reduction of the public sector, as
per the Washington Consensus.62,63 This consensus
emphasised macro economic stability and integration
with the international economy, with fundamental
elements including: public expenditure priorities, tax
reform, fi nancial and trade liberalisation, increased
foreign investment, privatisation, and a reduced role of
the state.62 In 1987, the World Bank promoted a report
that called for the introduction of user fees (ie, payment
contributed by patients at the point of care) as a main
component of cost-recovery schemes and a solution for
defi cits in public health budgets,64 although the World
Bank later reversed its position on user fees.
As a result, reduced public spending in social sectors
resulted in major defi cits in health—including lack of
drugs and competent professionals. These defi cits
contributed to patients seeking private care, leading to
what is referred to as passive privatisation. Additionally,
governments engaged in active privatisation policies,
including outsourcing of some clinical and non-clinical
services to private providers and investors in medical
industry. New liberal reforms were accompanied by
some political reforms aimed at reduction of the
government’s role in economic development and
weakening of planning functions. The World Trade
Organization pressured countries to accelerate free trade
in goods and services and to encourage private invest-
ment in medical industries, including in pharmaceutical
and medical equipment companies.
As part of structural adjustment programmes
initiated by organisations following the Bretton Woods
system, several countries in the region (including,
Egypt during the Hosni Mubarak era and Tunisia
during the Zine El Abidine Ben Ali era) started
gradually to withdraw state subsidies for social
programmes. In Egypt, Anwar Sadat’s policy of infi tah
(meaning openness or open door), announced in
October, 1974, aimed to reduce the state’s dominant role
in the economy and reorient the country towards
private initiatives and investments.65 However, in the
Mubarak era the government’s role in social welfare
programmes was reduced more sub stantially; spending
for health did not match the needs of the population
and resulted in high out-of-pocket expenditures and
worsening of quality of services.66,67 The delivery of
health care in Egypt was not equitable, with people
having low incomes spending dis proportionately larger
amounts on health than did those with higher
incomes.68,69 Similar to Egypt, the gap between health-
care demand and supply in Tunisia grew, worsening
inequity in access to health services despite the develop-
ment of the public sector and earlier improve ments in
living standards.70–75 Since the 1980s, the government
initiated active privatisation policies aimed to increase
private investment in health-care delivery.76 The result
was a substantial increase in the number of private
health-care facilities. The increasing demand for care in
the private sector was mainly caused by a gradual
disengagement of the state from the provision of care
services and by increased active privatisation policies.52
For instance, the Gini index of inequity (measuring the
extent to which consumption expenditure for indiv-
iduals within an economy deviates from a perfectly
equal distribution, with a Gini index of 0 representing
perfect equality and an index of 100 implying perfect
inequality) in Egypt and Tunisia is 30·8 and 41·4,
respectively (table 1).9
In Yemen, phase 2 co-incided with the unifi cation of
the formerly divided country. Perhaps counterintuitively,
such reunifi cation did not support development of
social services, nor did it put an end to the longstanding
armed confl icts.77 In contrast, in the post-reunifi cation
era, state-subsidised social programmes (including
health) seriously deteriorated in Yemen. This deterior-
ation was exacerbated by the economic crisis of the early
1990s.58 These events increased the pace of liberalisation
reforms with market tactics to subsidise the failing
public sector at the expense of both equity (Yemen’s
Gini index rank is 71) and quality.57 Since the mid-1990s,
these reforms of economic adjustment pro grammes
(introduced by international fi nancing institu tions)
have concentrated on privatisation and the fl ow of
foreign direct investment.78 Such modest reforms not
only failed to improve access to and quality of public
health services, but also increased the previously low
levels of inequity in the country.52,57,79,80
Libya, by contrast with Egypt, Tunisia, and Yemen, did
not follow the neoliberal movement that called for
approaches of minimum interference from government
and unrestricted markets for social services sectors (eg,
health and education).81 However, Libya undertook steps
to support transition to a more market-based economy,
www.thelancet.com Vol 383 January 25, 2014 373
including applying for World Trade Organization
membership, reducing subsidies, and considering
Phase 3: no global reversal of privatisation for countries
in the Arab world
For many people, the eff ects from promotion of
privatisation poli cies and
programmes, especially in developing countries, were
problematic.83 Findings from a comprehensive analysis
of the eff ects of user fees suggested that the fees failed to
deliver the benefi ts outlined in the World Bank agenda
for 1987 reform report,84 and were a barrier to access for
low-income and vulnerable populations.85–87 Additionally,
contrary to beliefs at their introduction, user fees proved
to be ineffi cient because their high administration costs
were almost equal to revenues, with little evidence of
their eff ect to reduce frivolous demand and redirect
patients to cost-eff ective services.84,88,89 In view of this
fi nding, many countries and international agencies
began to reconsider the structure of health fi nancing sys-
tems,84,90–95 beginning with World Health Assembly
Resolution 58.33, entitled “sustainable health fi nancing,
universal coverage and social health insurance”, which
was passed in 2005.96 The resolution urged member
states to restructure their fi nancing to make prepayment
the dominant method of fi nancial contribution, hence
discouraging the use of point-of-service payments.
However, although most developing countries have
reconsidered privatisation policies and user fees,
supported by evidence and the changing philosophy of
international agencies, many countries in the Arab world
have done the opposite.
Egypt continued to allocate fewer resources to health,
although demand for health care has increased because
of demographic changes (ie, population increases and
shifts in the burden of disease). As a result, most of
Egypt’s health spending (57%, with recent estimates
putting it as high as 72%) comes directly from household
out-of-pocket payments.6,97 At the same time, the Egyptian
Government has actively attempted to privatise health-
care services. Several health-insurance laws were
proposed by the government in the years before the
uprisings. In 2007, based on a ministerial decree, an
Egyptian Holding Company for Healthcare was created.
The decree moved all governmental health assets to
holdings of the newly established company for its for-
profi t operations.66 The decree was negated by the
Egyptian Court of Administrative Justice on Sept 4, 2008,
because it was unconstitutional.98
In its decision, the Court of Administrative Justice
“…leaving health provision to the private sector without
due regard to the reality of the economic situation of the
citizen and to the eff ect of that on the right to health.
Allowing the private sector to monopolise, control and
profi t from the diseases of the insured, fi rst by selling
the assets at the cheapest price because they will be sold
at book value and then by selling health services with a
for-profi t margin, even though it used to be off ered at
service cost by the HIO [Health Insurance Organization],
will ultimately change health insurance from a social
right, to a commercial project.”
A year later, in 2009, another insurance law was
proposed that echoed most of the earlier draft, most
prominently in the introduction or increase in formal
user fees. The planned implementation of new
regulations for health insurance would have made
patients contribute a large proportion of the costs of their
medical treatment (up to 25%) and prescriptions (up to
30%).99 The draft was discussed in a parliamentary
session in April, 2010, but its adoption was postponed
because of concerns of the Minister of Finance at the
time about the Egyptian Government’s ability to fi nance
In Tunisia, almost 95% of the population has insurance
coverage, either through government schemes for poor
and vulnerable groups (30%), or through social health
insurance for workers in public and private sectors
(65%) served by a national health insurance fund.100
Despite the presence of strong schemes for population
health coverage, the trend for privatisation has
continued. Between 1990 and 2008, the number of
private hospitals increased from 33 to 99, whereas the
increase in private bed capacity during the same period
was from 1142 to 2578 (2·3 times higher), with a low
average number of beds (26) per hospital. Strikingly,
despite annual increases in the budget of the Ministry of
Health (both running and investment), public facilities
were underfunded and medicines were often unavailable
because of budget spending limits. As a result, a two-tier
system of service provision has emerged—one for the
rich, who can aff ord to pay for high-quality private
health-care services, and one for the poor, who cannot
aff ord to pay and are served by a failing public sector100—
which has contributed to the erosion of Tunisians’ right
At the same time, and as part of continued and growing
endorsement of structural adjustment reforms initiated
by the government in the late 1980s, user fees were
established in public facilities to compensate for
diminishing government budgets.101 More importantly,
the increase in private investment in health was accom-
panied by a gradual reduction in government share of
total health expenditures, resulting from dis engagement
of the government from social spending (including
health).76,102 Out-of-pocket spending grew to nearly 45% in
2008. This increase is explained by several factors,
including active and passive privatisation generated by a
weak public sector, balance billing for insured patients in
the form of tariff s and co-payments, and provider-
induced demand caused by dual practice (ie, doctors and
other health-care staff holding more than one job)
promoted in public health-care institutions. Findings
www.thelancet.com Vol 383 January 25, 2014
from equity studies have shown an increase in the
number of households at risk of falling into poverty
because of cata strophic health-care expenditures, further
contributing to the level of inequity in Tunisia.103
In Yemen, phase 3 was characterised by further
deterioration of state-subsidised health services, aggra-
vated by serious sex and geographical inequities in use,
access, and quality of health services.104–106 The government
ran an ineffi cient and complex four-tiered health-care
system (primary care in health centres and units, secon-
dary care in district or governorate hospitals, tertiary care
in referral hospitals in Eden and Sana’a, and treatment
overseas for selected individuals79) with a parallel
subsystem running in the unregulated private sector.71
With regard to health fi nancing, structural economic and
administrative reforms initiated by the government in
the mid-1990s introduced nominal charges for services
(user fees) as a complementary funding mechanism for
the health system. These charges (which informally
increased with time) became a substantial fi nancial
burden for many people in Yemen. Eff orts in the past
decade to institute a national health-insurance system
have not materialised. This failure is of concern, because
in the same period public expenditure on health
decreased (from 35% to 28% of total health spending)
and out-of-pocket spending increased (from 57% to
71%).6 Additionally, major discrepancies in the pattern of
spending on health between rural and urban areas and
the distribution of fi nances between the 21 governorates
continued to increase.107
Unlike the other three countries, Libya had good natural
resources that enabled it to pursue UHC. Although the
country did not have a constitution, the right to free
health care was mentioned in some laws and bylaws.
However, erratic planning and poor use of valuable
resources prevented it from capitalising on the global
push towards UHC. For example, in 2000 a major
decentralisation project was launched by the government,
which included the abolition of several ministries
(including health and education) and the transfer of
substantial powers (eg, management of human resources,
fi nancial independence, and planning) to regional
authorities.108 This policy was accompanied by a huge
increase in the public-service workforce, from about
400 000 people in 2000 to 930 000 in 2005. Overstaffi ng in
the public sector was accompanied by an ineffi cient policy
of management of human resources and poor workforce
planning (eg, poor mix of skills). Falling wages and
unclear structures of responsibility led to widespread
absenteeism and ineffi cient use of human resources. In
response to the failure of decentralisation eff orts, the
government decided to recentralise the public adminis-
tration in 2006. Most of the ministries were recreated at
central level, but have remained fairly weak.109 In parallel,
the private sector has been passively encouraged to
increase its involvement in service provision.110 This
situation has resulted in a high level of supply of
health-care services (Libya, with 37 hospital beds per
10 000 people, has the highest number per person in sub-
Saharan Africa6) provided in a two-tier system, with
deteriorating quality of care and resultant poor trust in
public health-care facilities. Additionally, out-of-pocket
payments, which in principle should be similar to those
of the six countries of the Gulf Cooperation Council
(which have comparative national wealth), are sub-
stantially higher at 31·2%.111
In 2010, the onset of the Arab uprisings provided a
stepping stone towards a new phase of substantial
sociopolitical change in the four countries. Faced with
uprisings throughout the country, Zine El Abidine Ben Ali
fl ed Tunisia on Jan 14, 2011, after ruling the country for
24 years. Protests in Egypt forced Hosni Mubarak to
resign in February, 2011, after serving for fi ve consecutive
terms (1981–2011). However, major instability persisted
in Egypt beyond 2011. The Government of Egypt, led by
President Morsi, was challenged by huge public demon-
strations (June 30, 2013), which were followed by a
military intervention that overthrew Morsi and his
adminis tration, and appointed a new interim president
and cabinet. In November, 2011, Yemen’s President
Ali Abdullah Saleh signed an agreement to step down
and called for early elections in February, 2012. On Feb 21,
2012, presidential elections were held and Abdo Rabo
Mansour Hadi was elected as the new President of
Yemen. In March 2011, a National Tran sitional Council
was formed in Benghazi, Libya, with the stated aim of
overthrowing the Muammar Gaddafi regime and guiding
the country to democracy. After several months of
hostilities, the council took control of the capital Tripoli,
overthrowing the regime. In these uprisings, demo-
graphic, social, and economic boundaries were non-
existent. For example, the presence and active
par tici pation of women in the uprisings in Yemen and
Egypt was highly visible and instrumental. This partici-
pation is paving the way for more equitable policies as
shown in the new constitutions and governmental
policies of the Arab countries with the uprisings.
A roadmap for action after the uprisings
Our assumption is that the Arab uprisings have created a
sociopolitical momentum that should be capitalised on to
achieve UHC. This assumption is guided by similar
major sociopolitical changes in other countries. Yet, such
a path is rife with challenges that need serious con-
sideration by policy and decision makers (panel). Perhaps
the greatest challenge is one that is common to all
countries facing such major sociopolitical changes—ie,
nation building and instating of democracy. Recent events
in Egypt, Libya, and Tunisia, and to a lesser extent in
Yemen, are a reminder of the challenges that lie ahead to
reach a stable state capable of planning for and reaching
www.thelancet.com Vol 383 January 25, 2014 375
Panel: Challenges to reaching UHC in Arab uprising countries
UHC cannot be viewed solely from a health fi nancing
perspective, hence we have adopted a health sector-wide
approach to address the challenges presented below.
Weak focus on primary health care
Although the primary health-care model in Egypt includes
many community-based initiatives, it is applied as a medical
model and does not include a community-participatory
intersectoral approach. As a result, the system had a small
eff ect on health outcomes, particularly for disadvantaged
groups.112 In Tunisia, health-care facilities are located across the
country, allowing most of the population a ccess to primary
health-care services.101 Therefore, the system has a good
logistical access portfolio; the only restriction is related to
fi nancial access, when individuals have to pay user fees to get
care in public facilities (excluding preventive care). Yemen has
focused on primary health care as a cornerstone of
health-service provision because of its dispersed population
and more than 130 000 inhabited settlements in harsh
geographical terrain. However, the main challenge to expand
primary health services is the shortage of required fi nancing
and deployment of health staff to remote areas.
Unclear political landscape and social agenda
The election results in Egypt and Tunisia provided a stage for
Islamic parties to ascend as majorities in parliament and, most
probably, executive branches of government. However, these
election victories were based on disposing of existing regimes
rather than clear social programmes. Moreover, there is lack of
consensus (mostly between people supporting Islamic parties
and liberals) in some of the countries about the type of health
systems that should be instituted (eg, regarding access to
reproductive health services).
Investment in health and fragmented fi nancing systems
Investment in health is a major indicator of a country’s
commitment to the health of its citizens (eg, the Abuja
Commitment in 2001). From a fi nancing standpoint, UHC can
be best achieved through mandatory prepayment. From a
design perspective, this system is achieved through two routes:
national health insurance or service, or social health
insurance.113 Both approaches are challenging. First, in most
countries that implemented UHC using national health
insurance or service models and general tax revenue for
fi nancing, the tax-revenue system was well functioning.114,115
The problem in most low-income and middle-income
countries, including Arab countries with the uprisings, is that
the tax-revenue infrastructure is poor. Additionally, the Arab
countries with uprisings face unclear economic prospects.
Second, the social health insurance model relies heavily on
fi nancing from the population or contributions from
benefi ciaries; the presence of a substantial informal private
sector in the four countries might restrict the ability of the
system to depend on wages as a basis for contribution,2,116 in
addition to the problem of increased unemployment in these
countries. Another related concern is effi ciency—specifi cally,
fragmentation of fi nancing and the operation of public facilities
(eg, low occupancy, long length of stay).
Poor trust in public facilities
If UHC is to be pursued, government facilities should play a key
part in the service delivery system. Such a role is not possible
with the present lack of trust from the public regarding the
quality of care delivered in public settings. In Egypt, the level of
out-of-pocket payments to private providers signals patient
preference and trust in the private sector.117 In Tunisia, public
facilities have historically been the main provider of care for
the population. Although this role prevails to date, the increase
in the number of private providers and their scope of services
over the past two decades is of potential concern, especially if
coupled with the trend of decreasing capital investment by
government and operational defi cits in public facilities. In
Libya, the widespread distrust of quality of care in health-care
facilities meant that a multimillion dollar medical tourism
industry arose in neighbouring countries. In Yemen, both
public and private facilities are perceived as being of poor
quality and are not trusted.107
Sociopolitical instability and persisting emergencies
As with most uprisings that happened over history, the
post-uprising phase is characterised by lack of stability, both in
terms of security and societal functions,118,119 which is also
occurring in the Arab countries with uprisings. The general
unrest has resulted in disruption of health and social services120
in aff ected areas with mass refugee displacement to
neighbouring countries. As such, social programmes including
coverage and provision of health care cease to be the focus of
attention compared with ensuring of security and basic
Underdeveloped health information systems and evidence
for policy making
A properly functioning health information system has been
lauded as a cornerstone of any eff ective and equitable
health-care system.121 Unfortunately, health systems in many
low-income and middle-income countries are characterised by
a poor health information infrastructure,122 reducing their
ability to respond to challenges and to monitor systems
performance in a timely manner. This theme is common to
most low-income and middle-income countries, including
many in the Arab world. In Yemen, an assessment of the
national health information system in 2009 by the Health
Metrics Network123 showed that the system is highly
fragmented and ineffi cient with low-quality data. Egypt made
some progress with the establishment of the Epidemiology
and Disease Surveillance Unit at the Ministry of Public Health
in 2000, but information generation and sharing is still
(Continues on next page)
www.thelancet.com Vol 383 January 25, 2014
an optimum health system. We therefore present a road-
map for progression towards UHC (fi gure 3).
The main starting point for the path towards UHC is a
country’s commitment to the right to health. The pro-
posed roadmap acknowledges this right as a main pre-
requisite (as shown by societal values of solidarity and
political and economic commitments of government).
Many international entities discuss the notion of health as
a right, but the most used defi nition is that of the UN
Special Rapporteur Anand Grover from 2006: “the right to
an eff ective and integrated health system encompassing
health care and the underlying determinants of health,
which is responsive to national and local priorities, and
accessible to all. Underpinned by the right to health, an
eff ective health system is a core social institution, no less
than a court system or a political system.” However, even
before this defi nition, a general comment was adopted in
2000 by the UN Committee on Economic, Social and
Cultural Rights that operationalised all previous provisions
of the right to health. The comment outlined four com-
ponents of the right to health: suffi cient availability and
func tionality of public health and health-care facilities;
fi nancial and physical accessibility to services and infor-
mation in a non-discriminatory manner; ethical and
culturally appropriate acceptability, factoring in sex-
specifi c and age-specifi c sensitivities; and good quality
and appropriateness of care.129 UHC, although mainly
concerned with accessibility, should go beyond the fi nan-
cing component to ensure compliance with all four
components in the Arab countries with uprisings.
However, the discussions about right to health in the
four Arab countries with uprisings have not encom passed
the practical aspect of health-care delivery. This aspect is of
great importance because fi ndings from studies in
countries that have constitutional rights to health show
that the right does not translate into or ensure UHC.
Rather, the translation of that right into fi nancing,
governance, organisation, and delivery is crucial.42,130 The
four Arab spring countries are deliberating health coverage
as a priority in dialogues for new constitutions, national
policies, political party programmes, and missions for
non-governmental organisations, advocacy campaigns,
and media.131 In view of recent events in Egypt, the path the
new government will adopt is unclear. At the time this
report went to press, a constitutional review committee
had been instituted. In Tunisia, most political parties
expressed commitment to provide universal access to
health-care services during the election of the constitutional
assembly, which was reaffi rmed by the democratically
elected government after Oct 23, 2011. In Yemen, the new
government has included strengthening of health services
in its programme for action, increasing coverage and
(Continued from previous page)
Governance and institutional capacity (managerial and
organisational structures) at ministries of health and social
One of the main challenges in the countries being assessed in
this report is that the existing governance and organisational
structures in the public health sector have not been modifi ed
for a long time124–126—in some cases not since the earlier
revolutions that brought the previous regimes into power—
which is of special relevance for two reasons. First, the nature
of public health and health care has changed during the past
few decades, necessitating a modifi ed approach to health and
wellbeing. Second, the health systems have grown in depth
and breadth into complex systems with which existing
governance and organisational structures cannot cope
eff ectively and effi ciently.127 Reformation of these
organisational structures to ensure compatibility with the
requirements and challenges of a properly functioning
health-care system has been a predecessor of health-care
reforms in several countries.128 In Egypt, eff orts have been
made to decentralise institutional decision making to the
governorates. However, most major decisions relating to
organisational resources are still being made centrally,
especially at the Health Insurance Organization.117,127 Since the
end of the uprisings, health-care professionals in Libya have
formed infl uential lobby groups that have contested the
administrative, managerial, and policy-making structures that
previously existed in the public sector, especially the issue of
decentralisation. Many hospital directors and senior
government fi gures have been relieved of their duties to
make way for candidates deemed more acceptable to the
public. However, many of the replaced candidates might only
have been guilty by association with the old regime.
UHC=universal health coverage.
Figure 3: A framework for progression towards universal health coverage in Arab countries with uprisings
UHC=universal health coverage.
Coordinated donor engagement
Evidence-based policy making
• Estimation of
• Engineering of
www.thelancet.com Vol 383 January 25, 2014 377
improving quality of these services as part of commitments
for social and human development. In Libya, a national
health systems conference was held in 2012. A roadmap
for the future of health care was established that included a
path towards UHC.
Prerequisites and enablers
Only through active societal engagement can the
mistakes of earlier regimes be avoided. This engagement
should be structured as an integral part of the path
towards UHC—eg, through engagement with civil
society organisations and creation of a public engagement
commission. The role of the commission would be to
solicit and receive feedback from stakeholder groups,
individuals, and patients about existing or proposed
health-system elements or policies, and generate specifi c
recommendations to decision makers. The important
role of societal engagement has been discussed as a key
prerequisite for advancement towards UHC, whether in
understanding of the components of UHC or require-
ments to move forward.132 However, social advocacy is
needed, and is beginning to take shape. Findings from
polls taken after the uprisings in selected countries in the
region show that improved health care was a top priority
for people living in these countries.133 In Egypt, equity
campaigners and activists for social justice are involved
in ensuring a more equitable health-care system and
ultimately better health.112
However, for the countries discussed in this paper and
others in the Lancet Series about health in the Arab
world, sociopolitical and economic stability is an
important enabler. As with most uprisings in the past,
the post-uprising phase is characterised by lack of
stability, both in terms of security and societal
functions.118,119 General unrest after the Arab uprisings
has resulted in disruption of health and social services in
aff ected areas,120 with mass refugee displace ment to
neighbouring countries. As such, social programmes
(including coverage and provision of health care) cease to
be the focus of attention compared with ensuring of
security and basic societal needs. Political instability in
Egypt is of major concern, in view of the civil unrest
continuing through the preparation of this paper. In
Tunisia, the new government, operating in a near-
emergency mode, has not been able to articulate a clear
vision for social and economic development (including
health) and most pledges of international support for the
revolution have not yet materialised. A new cabinet is
under negotiation between the ruling Islamist Nahda
party and liberal parties in the country. Libya’s new
Ministry of Health has sought to revitalise the country’s
“shattered health system”,134 but the extremely high
burden of expectations placed on the new government
has resulted in a diffi cult political climate, in addition to
the serious security issues and calls for autonomy in the
region. These issues have made substantive progress
diffi cult and slow. The political instability in Yemen is
even more pronounced—the loss of the power of the
state has resulted in the appearance of armed groups in
several parts of the country. Additionally, there are
ongoing debates about how the post-uprising Yemen
should be governed. A federation is being discussed,
among other options. About half a million people are
estimated by the United Nations High Commissioner for
Refugees and the Offi ce for the Coordination of
Humanitarian Aff airs to be internally displaced.135,136 This
instability has postponed the social development agenda,
including that of UHC, because of more urgent issues
ranging from security to refuse collection and traffi c.
In the roadmap towards UHC, evidence-based decision
making and policy is a cross-cutting theme across all
health sector functions, which should start with design
of new or enhancement of existing health information
sys tems. A properly functioning health information
system is a cornerstone of any eff ective and equitable
health-care system.121 Unfortunately, health systems in
many low-income and middle-income countries are
characterised by poor health information infra-
structure,122 restricting the ability of these countries to
respond in a timely manner to challenges and to
eff ectively monitor the system’s performance. This
failure has been partly blamed on international donors,
who have actively contributed to the building of parallel
information systems that match their sponsored vertical
programmes, resulting in fragmen tation. A main role of
health information systems is to create information
feedback processes at diff erent health sector levels (eg,
central and local delivery platforms) that assess health
outcomes, processes, fi nancial, utilisation, and quality
indicators among others. Additionally, know ledge
translation hubs would assist in promotion of evidence
use in practice and policy. This implementation should
be done in partner ship with academic institutions to
ensure methodological rigour in design, execution, and
translation of evidence.
Stewardship and governance
In view of the challenges faced by Arab countries that
have had uprisings, practical steps need to be taken to
ensure that they can achieve UHC when the political
context is more stable. One of the main challenges is that
existing organisational structures in the public health
sector have not been modifi ed for a long time124–126—in
some cases, not since the revolutions that brought the
previous regimes into power—which is of special
relevance for two reasons. First, the nature of public
health and health care has changed during the previous
decades, necessitating a modifi ed approach to health and
wellbeing. Second, the needs of public health systems
have grown in depth and breadth into complex systems
that existing organisational structures cannot cope with
eff ectively and effi ciently.127 Reform of organisational
structure to ensure compatibility with the requirements
and challenges of a properly functioning health-care
www.thelancet.com Vol 383 January 25, 2014
system was a predecessor of health-care reforms in
several countries (eg, Thailand).128 Reinforcement and
con solidation of stewardship and governance in the
health-care sector should include initiatives such as
establishment of a national central coordinating com-
mittee for health (NCCH). We envision this committee to
represent all ministries and social insur ance organisations
that deal directly with health care to improve coordination
and effi cient use of resources (eg, delivery of funds and
services); the Ministry of Health should serve as the
secretariat for the NCCH. Experience from other
countries trying to achieve UHC showed that such a
unifi ed body is a crucial element to strengthen steward-
ship and form a collective decision making entity that
spans all stakeholders in the health sector (eg, the role of
the Consejo de Salubridad General [General Health
Council] in Mexico).41 In parallel, organisational struc-
tures or functions and institutional capacity should be
revised to ensure better effi ciency and higher account-
ability. A strategic plan (with a roadmap) to progress
towards UHC has to be subsequently devised and
endorsed by the NCCH.
Costs, fi nancing, and resources
The design of health-care fi nancing is key to UHC. Two
subcomponents are necessary. The fi rst is estimation of
UHC-related costs, which provides the means to assess
budgetary needs. Countries that are actively considering
UHC, such an India, are approaching the topic with
careful consideration of costs,137,138 as did other countries
that successfully introduced UHC.139 Costing can be
done on the basis of benefi t packages at each care level
(ie, primary, secondary, and tertiary). For some countries
of the Arab uprisings, this process might be complicated
and time-consuming. The alternative route is to esti-
mate the costs of service delivery on the basis of
historical trends, locality or facility feedback, and antici-
pation of what each uninsured person would use if they
were covered by UHC.140 Although not a preferred
approach, such a strategy could work in countries such
as Tunisia, which has an established record of pro-
gression towards UHC.12 Second, the engineering of
health-sector fi nancing is a main strategic activity that
needs the endorsement of stakeholders in health
care.113,141 The functions of gather ing, pooling, and
purchas ing have to be assessed, and strategic decisions
reached. The process also includes coordination with
international donors for development assistance for
health and technical assistance.
The degree and quality of service delivery coverage and
associated challenges vary among the four countries of
the Arab uprisings, and in the Middle East in general.142
Strengthening of delivery platforms, especially public
facilities, is a crucial step for progression towards UHC.11
For example, in its path towards UHC, Mexico coupled
fi nancial reforms with plans to strengthen supply
platforms (eg, hospitals, drug supply, surveillance, and
quality of care).41 Chile implemented similar changes in
its journey to UHC, and investments to strengthen
delivery platforms quadrupled from the 1980s to the
1990s.143 In all four Arab spring countries discussed in
this report, upgrading of infrastructure and existing
processes of care (rather than service capacity) is the
main challenge, especially for primary health care.144
Additionally, in Yemen service delivery platforms have
capacity and distribution issues. The ultimate aim of
these strategic investments is two-fold: provision of
adequate coverage and enhancement of trust in public
delivery system, both of which are key steps in the
achievement of UHC.145 However, the role and potential
contribution of the private sector cannot be ignored.
Public–private partnerships to enhance the path towards
UHC should be actively considered.
Most countries that have progressed to UHC did so in a
phased approach.146 The four countries examined in this
report, as well as others in the Arab world, have a golden
opportunity to capitalise on the social equity dynamic
created as a result of the uprisings to progress towards
UHC. This process will be diffi cult and time-consuming,
and will need solid commitment at all levels. Com-
promises will be needed at each stage to move the process
forward. However, the risks of in action at this stage are
substantial. UHC should continue to be advocated as a
cornerstone to a more equitable society—as much of a
right as an investment. If policy makers and societies in
the Arab countries with uprisings do not focus on UHC,
it will be lost to the many other priorities and challenges
that these countries are facing. To continue on this path,
one issue should not be compromised: the right of indiv-
iduals to health.
All authors contributed to the design of the paper. SSS, AM, BS, SSi, and
MSA contributed to the conceptualisation. SSS, MSA, and NMN
coordinated data collection, review, and data analysis. SSS and NMN
prepared the fi rst draft. Country sections were prepared and analysed by
SA, MZ, JN, and BS. SSS, MSA, and NMN formulated the fi nal review
of inputs and information from all coauthors and integrated the fi nal
version. All authors reviewed and approved the fi nal version.
Confl icts of interest
We declare that we have no confl icts of interest.
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