ACHIEVING HEALTH EQUITY
REPORT OF THE COMMISSION ON SOCIAL DETERMINANTS OF HEALTH IN THE EASTERN MEDITERRANEAN REGION
IN THE EASTERN MEDITERRANEAN REGION
BUILD BACK FAIRER
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WHO Library Cataloguing in Publication Data
Names: World Health Organization. Regional Office for the Eastern Mediterranean, Institute of Health Equity, Alliance for Health Policy and Systems Research Title: Build back fairer: achieving health equity in the Eastern Mediterranean Region: report of the Commission on Social Determinants of Health in the Eastern Mediterranean Region / World Health Organization. Regional Office for the Eastern Mediterranean, Institute of Health Equity, Alliance for Health Policy and Systems Research Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, 2021 | Includes bibliographical references. Identifier: ISBN 978-92-9274-319-2 (pbk.) | ISBN 978-92-9274-320-8 (online) Subjects: Health Equity | Healthcare Disparities | Social Determinants of Health | Health Status Disparities | COVID-19 | Betacoronavirus | Disease Outbreaks | Eastern Mediterranean Region Classification: NLM W 76
This publication was originally published under ISBN: 978-92-9022-867-7, 978-92-9022-868-4
ACHIEVING HEALTH EQUITY
REPORT OF THE COMMISSION ON SOCIAL DETERMINANTS OF HEALTH IN THE EASTERN MEDITERRANEAN REGION
IN THE EASTERN MEDITERRANEAN REGION
BUILD BACK FAIRER
NOTE FROM THE CHAIR
CHAPTER 1: INTRODUCTION TO THE COMMISSION
BUILD BACK FAIRER THE COMMISSION: AIMS AND OBJECTIVES SOCIAL DETERMINANTS OF HEALTH AND HEALTH EQUITY BUILDING BACK FAIRER AND HEALTH EQUITY: CONCEPTUAL APPROACH FILLING THE EVIDENCE GAPS
DO SOMETHING, DO MORE, DO BETTER LEVELS OF DEVELOPMENT AND HEALTH EQUITY ACROSS THE REGION THE SOCIAL PROGRESS INDEX
SUMMARY
CHAPTER 2: HEALTH INEQUITIES IN THE REGION
INTRODUCTION
DATA AVAILABILITY
LIFE EXPECTANCY HEALTHY LIFE EXPECTANCY (HALE)
INFANT AND UNDER-5 MORTALITY
LEADING CAUSES OF PREMATURE MORTALITY
NCDS OBESITY PHYSICAL ACTIVITY FOOD INSECURITY UNDERNOURISHMENT TOBACCO USE ALCOHOL USE
MENTAL HEALTH
COMMUNICABLE DISEASES TUBERCULOSIS HIV VECTOR-BORNE DISEASES CHOLERA
VIOLENCE AND ROAD TRAFFIC DEATHS
SUMMARY AND RECOMMENDATIONS
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TABLE OF CONTENTS
CHAPTER 3: COVID-19 AND INEQUITIES
INTRODUCTION
INFECTION AND MORTALITY FROM COVID-19 IN THE REGION
INEQUITIES IN RISK OF INFECTION AND MORTALITY FROM COVID-19 UNDERLYING HEALTH CONDITIONS AND RISK OF COVID-19 MORTALITY INEQUITIES IN LIVING CONDITIONS AND RISK OF INFECTION INEQUITIES IN COVID-19 MORTALITY BY OCCUPATION INEQUITABLE ACCESS TO HEALTH CARE AND COVID-19 MORTALITY INEQUITIES IN ACCESS TO HEALTH INFORMATION
INEQUITIES AS A RESULT OF CONTAINMENT MEASURES INCREASING POVERTY AND INCOME INEQUITIES JOB LOSSES AND REDUCTIONS IN WORKING HOURS INEQUITIES AND INFORMAL WORK AND MIGRANT WORKERS RISING LEVELS OF FOOD INSECURITY AND UNDERNUTRITION SCHOOL CLOSURES LIVING CONDITIONS INCREASE IN GENDER INEQUALITIES SOCIAL EXCLUSION AND STIGMA DISRUPTIONS TO HEALTH CARE SERVICES
MEASURES TO MITIGATE THE INEQUITABLE IMPACTS OF COVID-19 SOCIAL PROTECTION PROGRAMMES THE UNITED NATIONS AND NONGOVERNMENTAL ORGANIZATIONS COVAX FACILITY AND VACCINATIONS IN THE REGION
BUILDING BACK FAIRER IN RESPONSE TO COVID-19
SUMMARY AND RECOMMENDATIONS
CHAPTER 4: CONFLICT AND CONSEQUENCES AND MIGRATION
INTRODUCTION
CONFLICT IN THE REGION
MIGRATION IN THE REGION DRIVERS OF MIGRATION HEALTH AND MIGRATION REGISTRATION AND LEGAL STATUS OF MIGRANTS
APPROACHES TO IMPROVE HEALTH AND CONDITIONS FOR REFUGEES AND MIGRANTS
DATA LIMITATIONS
THE IMPACT OF SANCTIONS IN THE REGION
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ECONOMIC IMPACTS OF SANCTIONS FOOD AVAILABILITY EDUCATION REDUCING THE INEQUITABLE HEALTH IMPACTS OF SANCTIONS
HEALTH INEQUITIES, OCCUPATION AND THE OCCUPIED PALESTINIAN TERRITORY CONSEQUENCES OF OCCUPATION ON HEALTH IN THE OCCUPIED PALESTINIAN TERRITORY
SUMMARY AND RECOMMENDATIONS
CHAPTER 5: ECONOMIC DRIVERS OF HEALTH INEQUITIES
INTRODUCTION
INCOME AND POVERTY POVERTY IN THE REGION MECHANISMS TO SUPPORT THOSE IN POVERTY
INCOME INEQUITIES IN THE REGION
TAXATION
LEVELS OF SOCIAL PROTECTION
GOVERNMENT INVESTMENT IN PUBLIC SERVICES
COMMERCIAL DETERMINANTS OF HEALTH POLITICAL LEADERSHIP LEGAL MECHANISMS AND REGULATIONS FINANCIAL SYSTEMS MARKETING AND INFLUENCING PURCHASING AND BEHAVIOURS
MEASURES OF PROGRESS
OFFICIAL DEVELOPMENT ASSISTANCE
SUMMARY AND RECOMMENDATIONS
CHAPTER 6: CULTURE AND SOCIETY
INTRODUCTION
RELIGION AND IDENTITY AND HEALTH EQUITY RELIGION AND HEALTH RELIGION AND THE SOCIAL DETERMINANTS OF HEALTH
GENDER AND HEALTH INEQUITIES IN THE REGION CARING ROLES
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TABLE OF CONTENTS
GENDER-BASED VIOLENCE IN THE REGION GENDER-BASED VIOLENCE AND REFUGEES AND IDPs COVID-19 AND GENDER-BASED VIOLENCE REDUCING GENDER INEQUITIES
ATTITUDES TOWARDS MIGRANTS
SUMMARY AND RECOMMENDATIONS
CHAPTER 7: THE NATURAL ENVIRONMENT AND HEALTH EQUITY
INTRODUCTION
CLIMATE CHANGE AND HEALTH EQUITY IN THE REGION DIRECT IMPACTS OF CLIMATE CHANGE ON HEALTH IMPACTS OF CLIMATE CHANGE ON THE SOCIAL DETERMINANTS OF HEALTH LIVING CONDITIONS AND CLIMATE CHANGE POVERTY AND CLIMATE CHANGE WORK AND CLIMATE CHANGE DISPLACED PEOPLE, REFUGEES, MIGRATION AND CLIMATE CHANGE CONFLICT AND CLIMATE CHANGE
GREENHOUSE GAS EMISSIONS IN THE REGION EMISSIONS BY SECTOR AIR CONDITIONING TRANSPORT AGRICULTURAL EMISSIONS
REDUCING GREENHOUSE GAS EMISSIONS RENEWABLES IN THE REGION COST OF RENEWABLES IN THE REGION CO-BENEFITS OF RENEWABLE ENERGY IN THE REGION REDUCING ENERGY CONSUMPTION ENERGY AND WATER SUBSIDIES
WATER SCARCITY AND WATER POLLUTION IN THE REGION WATER SCARCITY, WATER QUALITY AND HEALTH WATER CONSERVATION STRATEGIES WATER MANAGEMENT, RECYCLING AND TREATING WATER SECURING WATER SUPPLY
LAND DEGRADATION IN THE REGION DESERTIFICATION DUST AND SANDSTORMS DEFORESTATION LOSS OF BIODIVERSITY
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EXTREME WEATHER EVENTS
SUMMARY AND RECOMMENDATIONS
CHAPTER 8: EQUITY IN MATERNAL AND CHILD HEALTH, THE EARLY YEARS AND EDUCATION
INTRODUCTION
MATERNAL AND NEWBORN HEALTH MATERNAL AND NEWBORN OUTCOMES ACCESS TO MATERNAL HEALTH SERVICES MATERNAL NUTRITION CHILD MARRIAGE AND ADOLESCENT FERTILITY ACCESS TO MODERN CONTRACEPTION IMPACT OF COVID-19 ON MATERNAL AND REPRODUCTIVE HEALTH
CHILD HEALTH CHILD HEALTH OUTCOMES NUTRITION: INFANTS AND EARLY YEARS HEALTH PROTECTION MEASURES FOR INFANTS AND CHILDREN
THE EARLY YEARS AND EDUCATION EARLY CHILDHOOD DEVELOPMENT EARLY CHILDHOOD EDUCATION
EDUCATION PARTICIPATION IN PRIMARY SCHOOL SECONDARY SCHOOL COMPLETION NATIONAL EDUCATION POLICIES TO REDUCE INEQUITIES YOUNG PEOPLE NOT IN EDUCATION, EMPLOYMENT OR TRAINING TERTIARY EDUCATION ATTAINMENT INEQUITIES ACROSS THE REGION GOVERNMENT EXPENDITURE ON EDUCATION
SUMMARY AND RECOMMENDATIONS
CHAPTER 9: WORKING LIVES AND HEALTH EQUITY
INTRODUCTION
OVERVIEW OF EMPLOYMENT IN THE EASTERN MEDITERRANEAN REGION UNEMPLOYMENT SOCIAL PROTECTIONS FOR UNEMPLOYMENT
EMPLOYMENT BY SECTOR
INFORMAL EMPLOYMENT
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TABLE OF CONTENTS
FEMALE PARTICIPATION IN THE LABOUR FORCE
YOUTH EMPLOYMENT
EMPLOYMENT IN FRAGILE AND CONFLICT-AFFECTED STATES
RATES OF PAY
WORKING CONDITIONS AND OCCUPATIONAL SAFETY MIGRANTS AND REFUGEES
TRAFFICKING AND SLAVERY
CHILD LABOUR
COVID-19 AND EMPLOYMENT
SUMMARY AND RECOMMENDATIONS
CHAPTER 10: HEALTHY AGEING
INTRODUCTION
DEMOGRAPHIC SHIFTS IN THE EASTERN MEDITERRANEAN REGION
HEALTH AND DISABILITY AMONG OLDER PEOPLE
MENTAL HEALTH OF OLDER PEOPLE
SOCIOECONOMIC INEQUITIES IN HEALTH AMONG OLDER PEOPLE
POLICIES TO SUPPORT THE HEALTH AND WELL-BEING OF OLDER PEOPLE
SOURCES OF SUPPORT FOR OLDER PEOPLE
POVERTY IN OLDER PEOPLE
INEQUITIES IN ACCESS TO SOCIAL PROTECTION FOR OLDER PEOPLE
INEQUITIES IN ACCESS TO HEALTH AND CARE AND OTHER SERVICES FOR OLDER PEOPLE
OLDER PEOPLE AND ABUSE
SUPPORT FOR ACTIVE, HEALTHY AGEING
SUMMARY AND RECOMMENDATIONS
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CHAPTER 11: BUILT ENVIRONMENTS AND HEALTH EQUITY
INTRODUCTION
PLANNING STRATEGIES
TRANSPORT PUBLIC TRANSPORT AND ACTIVE TRANSPORT TRANSPORT SAFETY
HOUSING CONDITIONS HOUSING AFFORDABILITY
INFORMAL SETTLEMENTS
ACCESS TO CLEAN WATER AND SANITATION ACCESS TO SAFELY MANAGED SANITATION SERVICES WASTE MANAGEMENT
ACCESS TO ELECTRICITY
ACCESS TO THE INTERNET
AIR POLLUTION
SUMMARY AND RECOMMENDATIONS
CHAPTER 12: HEALTH SYSTEMS FOR HEALTH EQUITY
INTRODUCTION
UNIVERSAL HEALTH COVERAGE PLACE OF RESIDENCE GENDER EDUCATION INCOME
FINANCING HEALTH SERVICES
PRIMARY HEALTH CARE SYSTEMS
CONFLICT AND ACCESS TO HEALTH CARE
MIGRANTS, REFUGEES AND DISPLACED POPULATIONS
PUBLIC HEALTH SYSTEMS ESSENTIAL PUBLIC HEALTH FUNCTIONS HEALTH PROMOTION IMMUNIZATION PROGRAMMES
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TABLE OF CONTENTS
POPULATION HEALTH SYSTEMS THE HEALTH WORKFORCE HEALTH CARE ORGANIZATIONS AS ANCHOR INSTITUTIONS
SUMMARY AND RECOMMENDATIONS
CHAPTER 13: GOVERNANCE AND TAKING ACTION TO BUILD BACK FAIRER
INTRODUCTION
PRINCIPLES FOR GOVERNANCE TO BUILD BACK FAIRER TAKE ACTION ON SOCIAL DETERMINANTS OF HEALTH TO IMPROVE HEALTH EQUITY PUT HEALTH EQUITY AT THE HEART OF GOVERNMENT DO SOMETHING, DO MORE, DO BETTER ADOPT PROPORTIONATE UNIVERSALISM INVOLVE THE WHOLE OF GOVERNMENT IN IMPROVING HEALTH EQUITY INVOLVE THE WHOLE OF SOCIETY IN IMPROVING HEALTH EQUITY DEVELOP STRONG ACCOUNTABILITY FOR HEALTH EQUITY ALIGN GREATER ACTION ON CLIMATE CHANGE WITH HEALTH EQUITY
TAKING ACTION TO BUILD BACK FAIRER DEVELOP NATIONAL AND TRANSNATIONAL ACTION PLANS ON SOCIAL DETERMINANTS AND HEALTH EQUITY STRENGTHEN THE ROLE OF CIVIL SOCIETY AND FAITH-BASED ORGANIZATIONS STRENGTHEN THE CONTRIBUTION OF THE COMMERCIAL SECTOR TO HEALTH EQUITY SUPPORT THE HUMANITARIAN SECTOR TO HAVE A STRONG FOCUS ON SOCIAL DETERMINANTS OF HEALTH INCREASE INVOLVEMENT OF HEALTH CARE SECTOR IN SOCIAL DETERMINANTS OF HEALTH DEVELOP THE ROLE OF LOCAL GOVERNMENT IN THE SOCIAL DETERMINANTS OF HEALTH LINK ACTION ON HEALTH EQUITY AND SOCIAL DETERMINANTS OF HEALTH WITH THE SDGS STRENGTHEN HUMAN RIGHTS APPROACHES IN THE REGION DEVELOP DATA AND MONITORING SYSTEMS TO INFORM EVIDENCE-BASED ACTION ON HEALTH EQUITY, TRANSPARENCY AND ACCOUNTABILITY STRENGTHEN LEGAL OBLIGATIONS AND REGULATIONS TO SUPPORT HEALTH EQUITY REDUCE CORRUPTION
RESEARCH AGENDA RESEARCH RECOMMENDATIONS
RECOMMENDATIONS FOR MAIN STAKEHOLDERS ACTIONS FOR INTERNATIONAL ORGANIZATIONS ACTIONS FOR WHO ACTIONS FOR NATIONAL GOVERNMENTS ACTIONS FOR MINISTRIES OF HEALTH ACTIONS FOR LOCAL GOVERNMENT ACTIONS FOR CIVIL SOCIETY AND FAITH-BASED ORGANIZATIONS
497 499 500
501
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505 506 507 507 508 508 509 510 514
515 515
520 524 526
527 528 530 534 537
539 545
545 546
548 548 550 552 555 557 558
AFESD Arab Fund for Economic and Social Development
AMU Arab Maghreb Union
COVAX COVID-19 Vaccines Global Access
COVID-19 coronavirus disease 2019
CPI Corruption Perceptions Index
CSR corporate social responsibility
DAH development assistance for health
DHS Demographic Health Surveys
EiEWG Education in Emergencies Working Group (EiEWG),
ESCWA Economic and Social Commission for Western Asia
EU European Union
FAO Food and Agriculture Organization of the United Nations
FGM female genital mutilation
GAFTA Greater Arab Free Trade Area
GCC Gulf Cooperation Council
GDP gross domestic product
GEM Scale Gender-Equitable Men Scale
GLAAS Global Analysis and Assessment of Sanitation and Drinking water
GNI gross national income
GW gigawatts
HALE Health-adjusted life expectancy
HDI Human Development Index
Urban HEART Urban Health Equity Assessment and Response Tool
HEAT Health Equity Assessment Toolkit
HiAP Health in All Policies
IAG Islamic Advisory Group for Polio Eradication
ICOPE integrated care for older people
IDS internally displaced persons
IFAD International Fund for Agricultural Development
ILO International Labour Organization
IMAGES MENA International Men and Gender Equality Survey – Middle East and North Africa
IMCI Integrated Management of Childhood Illness
IMF International Monetary Fund
IOM International Organization for Migration
IPC Integrated food security Phase Classification
IPCC Intergovernmental Panel on Climate Change
ABBREVIATIONS AND ACRONYMS
x
JMP Joint Monitoring Programme
MENARAH Middle East and North Africa Research on Ageing Healthy
MICS Multiple Indicator Cluster Surveys
MSF Médecins Sans Frontières
NCD noncommunicable disease
NDC nationally determined contribution
NHS National Health Service
OCHA United Nations Office for the Coordination of Humanitarian Affairs
ODA official development assistance
OECD Organisation for Economic Co-operation and Development
OHCHR Office of the United Nations High Commissioner for Human Rights
OPEC Organization of the Petroleum Exporting Countries
PPE personal protective equipment
PPP purchasing power parity
SARS severe acute respiratory syndrome
SARS-CoV-2 severe acute respiratory syndrome coronavirus 2
SCI Service Coverage Index
SDGs Sustainable Development Goals
SPFI Social Protection Floor Index
SPI Social Progress Index
SROI social return on investment
SWF sovereign wealth fund
UN-Habitat United Nations Human Settlements Programme
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNEP United Nations Environment Programme
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFCC United Nations Framework Convention on Climate Change
UNFPA United Nations Population Fund
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East
USAID United States Agency for International Development
WASH water, sanitation and hygiene
WFP World Food Programme
WHO World Health Organization
YLL years of life lost
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BUILD BACK FAIRER: ACHIEVING HEALTH EQUITY IN THE EASTERN MEDITERRANEAN REGION
CHAPTER 1: INTRODUCTION TO THE COMMISSION
Figures Fig. 1.1. The WHO Eastern Mediterranean Region Fig. 1.2. Framework for the social determinants of health in the Eastern Mediterranean Region Fig. 1.3. Life expectancy at birth by GNI per capita, (2017 PPP $) in the Region, 2019 Fig. 1.4. Difference in ranking by GNI per capita and by HDI value in countries and territories in the Region, 2019 Fig. 1.5. Over- and underperformers on the SPI relative to GDP compared with the world average, 2020 Fig. 1.6. Countries and territories of the Region by GNI per capita (2017 PPP $) 2019 and SPI scores 2020
Tables Table 1.1. HDI score and rank and GNI of countries and territories in the Region, 2019
Boxes Box 1.1. UNDP Human Development Index Box 1.2. The Social Progress Index
CHAPTER 2: HEALTH INEQUITIES IN THE REGION
Figures Fig. 2.1. Coverage of death registration (%) in countries and territories in the Region, 2015 Fig. 2.2. Completeness of cause-of-death registration (%) by country, 2009–2017 Fig. 2.3. Coverage of birth registration (%) in countries and territories in the Region, 2015 Fig. 2.4. Reporting on regional core indicators and SDG indicators by countries and territories in the Region, 2014 and 2018 Fig. 2.5. Trends in life expectancy at birth in countries in the Region, 2000–2019 Fig. 2.5. a) Life expectancy at birth, by country, 2000–2019 Fig. 2.5. b) Life expectancy at birth for males, 2000–2019 Fig. 2.5. c) Life expectancy at birth for females, 2000–2019 Fig. 2.6. Life expectancy in countries in the Region, by sex, 2019 Fig. 2.7. Percentage contribution (%) of inequity in HDI dimensions to reduction in Jordan’s overall HDI, 2017 Fig. 2.8. Estimated life expectancy at birth (both sexes) in 22 districts of Tehran, Islamic Republic of Iran, 2010 Fig. 2.9. Healthy life expectancy (HALE) at birth in countries in the Region, by sex, 2019 Fig. 2.10. Healthy life expectancy (HALE) at age 60 years in countries in the Region, by sex, 2019 Fig. 2.11. Infant mortality rate in countries and territories in the Region, 2019 Fig. 2.12. Trends in infant mortality rate in countries and territories in the Region, 2009–2019 Fig. 2.13. Infant mortality rate in selected countries and territories, by wealth quintile, 2013–2018 Fig. 2.14. Under-5 mortality rate in countries and territories in Region, 2009–2019 Fig. 2.15. Leading causes of premature death (YLLs) in the Region, 2005–2015 and percent change Fig. 2.16. Probability (%) of dying between exact ages 30 and 70 from any cardiovascular disease, cancer, diabetes or chronic respiratory disease, by country, 2016 Fig. 2.17. Prevalence (%) of overweight and obesity (age-standardized estimates) in adults aged 18 years and older, by country, 2016 or latest available year Fig. 2.18. Prevalence (%) of obesity (age-standardized estimate) among adults aged 18 years or older, by country and gender, 2016 or latest available year Fig. 2.19. Prevalence (%) of overweight (age-standardized) in adults aged 18 years and older, by WHO region, 2016
LIST OF FIGURES, TABLES AND BOXES
xii
Fig. 2.20. Prevalence (%) of obesity in countries of the Middle East and North Africa, by sex, 1990 and 2016 Fig. 2.21. Prevalence (%) of overweight in children aged under 5 in countries and territories in the Region, 2018 or latest available year Fig. 2.22. Prevalence (%) of obesity in non-pregnant women aged 15–49 years in selected countries in the Region, by wealth quintile, 2013–2017 Fig. 2.23. Prevalence (%) of obesity by level of education in Egypt, between 1992/1995 and 2005/2008 Fig. 2.24. Prevalence (%) of diabetes based on blood glucose level (HbA1c) in Islamic Republic of Iran, by wealth quintile, 2016 Fig. 2.25. Prevalence (%) of diabetes in Jordan, by education, 2017 Fig. 2.26. Prevalence (%) of insufficient physical activity (age-standardized estimate) among adults aged 18 years and older in selected countries in the Region, 2016 Fig. 2.27. Prevalence (%) of moderate or severe food insecurity in selected countries in the Region, 2014/2016 and 2017/2019 Fig. 2.28. Prevalence (%) of undernourishment in selected countries in the Region, 2017 Fig. 2.29. Population below minimum level of dietary energy requirement (undernourishment) (%) in selected countries in the Region, between 1999 and 2018 Fig. 2.30. Prevalence (%) of current tobacco smoking (age-standardized) among people aged 15 years and older in selected countries, by sex, 2018 estimates Fig. 2.31. Trends in prevalence (%) of current tobacco use among of adults aged 15 years and older in selected countries, 2010–2018 Fig. 2.32. Tobacco use at age 13–15 years in selected countries and territories, 2018 or latest available year Fig. 2.33. Prevalence of cigarette smoking (%) in selected countries, by wealth quintile and sex, 2005–2012 Fig. 2.34. Country-weighted mean prevalence estimates of regular or occasional use of waterpipe, by WHO region, 2018 Fig. 2.35. Total alcohol consumption per capita per year (litres of pure alcohol, projected estimates), by country and sex, 2018 Fig. 2.36. Distribution of DALYs (%) due to mental disorders in the Region, by diagnosis, 2017 Fig. 2.37. Prevalence (%) of depressive disorders (age-standardized) in countries and territories in the Region, 2016 Fig. 2.38. Share of population (%) with anxiety disorders (age-standardized) in countries and territories in the Region, 2017 Fig. 2.39. Suicide mortality rate in countries of the Region, by sex, 2016 Fig. 2.40. Incidence of tuberculosis in countries and territories in the Region, 2019 Fig. 2.41. Regional estimates of tuberculosis incidence (black outline) and case notifications disaggregated by age and sex (female in purple; male in green), 2019 Fig. 2.42. HIV incidence by WHO region, 1990–2019 Fig. 2.43. Incidence of HIV infections (per 1000 uninfected population) by country, 1990–2019 Fig. 2.44. Estimated number of new HIV infections in Pakistan, 2010–2018 Fig. 2.45. Estimated number of AIDS-related deaths in Pakistan, 2010–2019 Fig. 2.46. Cases of cutaneous leishmaniasis reported, by country, 2005–2019 Fig. 2.47. Cholera deaths and case fatality rate (deaths per 1000 cases) in Somalia and Yemen, January–December 2020 Fig. 2.48. Intentional homicides in countries and territories in the Region, 2018 or latest available year Fig. 2.49. Road traffic fatality rates (per 100 000 population) in high-income countries, by WHO region, 2016 Fig. 2.50. Road traffic deaths in the Region, WHO estimates and country-reported data, 2017 Fig. 2.51. Distribution of road traffic deaths in selected countries, by type of road user, 2016
Tables Table 2.1. Life expectancy and healthy life expectancy (HALE) at birth, regional and global estimates, 2016 Table 2.2. Estimates of the burden of major vector-borne diseases in the Region, 2015
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BUILD BACK FAIRER: ACHIEVING HEALTH EQUITY IN THE EASTERN MEDITERRANEAN REGION
CHAPTER 3: COVID-19 AND INEQUITIES
Figures Fig. 3.1. COVID-19 deaths (per million population) in countries and territories of the Region, 28 February 2021 Fig. 3.2. Forecast of extreme poverty (less than US$ 1.90 per day) in the Middle East and North Africa, 2017–2021 Fig. 3.3. Estimated increase in poverty as a result of the COVID-19 crisis among Syrian refugees in Jordan, the Kurdistan region of Iraq, and Lebanon, 2020 Fig 3.4. Proportion of IDPs in Iraq experiencing adverse impacts of the COVID-19 crisis, 2020 Fig. 3.5. Refugee households’ response to the COVID-19 situation in Lebanon, comparison of weeks 1–20, 2020 Fig. 3.6. Effect of the COVID-19 pandemic on work in Egypt, 2020 Fig. 3.7. Workers who stopped working (%) in selected countries in the Region, by income quintile, 2020 Fig. 3.8. Percentage of workers receiving payment while not working in Tunisia, 2020 Fig. 3.9. Urgent support wanted by residents in Gilgit‐Baltistan, Pakistan, May 2020 Fig. 3.10. Changes in food consumption due to COVID-19 in Tunisia, by wealth quintile, 2020 Fig. 3.11. Change in food basket cost in selected countries in the Region, January–September 2020 Fig. 3.12. Share of households unable to access schools in Yemen, 2019 and 2020 Fig. 3.13. Changes in violence against women in the Arab States during the COVID-19 pandemic, as reported by civil society organizations, 2020 Fig. 3.14 Share of population receiving cash transfer in Djibouti, Egypt and Tunisia, by income quintile, 2020
Tables Table 3.1. Projected poverty increases due to COVID-19 and oil price collapse, in selected countries and territories in the Region Table 3.2. Working hours lost and equivalent full-time job losses, by region, January–September 2020 Table 3.3. Percentage change in nutrition support, in selected countries and territories in the Region, March–August 2020 Table 3.4. Members of COVID-19 decision-making task forces in selected countries in the Region, June 2020 Table 3.5. Estimated decline in child vaccinations due to COVID-19 crisis in Afghanistan, Iraq and Pakistan Table 3.6. COVAX Facility participation status in the Middle East and North Africa, by country, as at 4 January 2021
Boxes Box 3.1. Community health workers and COVID-19 in the Region Box 3.2. Inclusive care during the COVID-19 pandemic in Jordan Box 3.3. Impacts of COVID-19 on food insecurity Box 3.4. Examples of support in the Region Box 3.5. Initiatives by faith-based organizations during the pandemic Box 3.6. Reducing inequities to protect health in Tunisia
CHAPTER 4: CONFLICT AND CONSEQUENCES, AND MIGRATION
Figures Fig. 4.1. Total deaths (in thousands) per year from war and terrorism, by WHO region, 1990–2017 Fig 4.2. Conflict and terrorism deaths (per 100 000 population) in selected countries and territories in the Region, 1990–2017
LIST OF FIGURES, TABLES AND BOXES
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Fig 4.3. Percentage of deaths caused by conflict and terrorism, by country and territory, 2009–2019 Fig 4.4. Number of refugees (in thousands) in host countries and territories in the Region, 2019 Fig 4.5. Total number of immigrants (in thousands) by country and territory of destination in the Region, 2018 Fig 4.6. Number of international migrants (in thousands) by country and territory in the Region, 2019 Fig 4.7. Unemployment and inward migration in the Region, 2018 Fig 4.8. Infant and neonatal mortality rates in the Gaza Strip, 2008, 2013 and 2015
Tables Table 4.1. Direct and indirect consequences of conflict on health and the social determinants of health Table 4.2. Selected health-related indicators in the occupied Palestinian territory and the Region, 2018
Boxes Box 4.1. Examples of promising mental health interventions in post-conflict settings Box 4.2. Conflict and education Box 4.3. Health profile of Palestinian refugees Box 4.4. Regional action plan to promote the health of migrants, refugees and displaced populations (2019) Box 4.5. Social assistance programmes in Jordan for Syrian refugees Box 4.6. Initiatives for improving working conditions for economic migrants in GCC countries Abu Dhabi Dialogue Box 4.7. Restrictions on employment of Palestinian refugees in Lebanon Box 4.8. Pakistan and legal residency for Afghan refugees Box 4.9. Programmes to integrate refugees and provide an economic boost for host countries Box 4.10. The 2018 Global Compact for Safe, Orderly and Regular Migration Box 4.11. Afghanistan population movement monitoring system Box 4.12. The UCL-Lancet Commission on Migration and Health Box 4.13. Health impacts of sanctions in Iraq, 1990–2003 Box 4.14. Sanctions and COVID-19 Box 4.15. Electricity shortages in the Gaza Strip Box 4.16. UNRWA activities in primary education
CHAPTER 5: ECONOMIC DRIVERS OF HEALTH INEQUITIES
Figures Fig 5.1. GNI per capita, PPP (current international $) in countries in the Region, 2019 or latest available year Fig 5.2. GNI per capita, PPP (current international $) in selected countries in the Region, 2000–2019 or latest available year Fig 5.3. Poverty versus life expectancy at birth, in selected countries in the Region, 2014 Fig 5.4. Percentage of population living in extreme poverty (less than $ 1.90 per day at 2011 international prices) in countries and territories in the Region with available data, 2000, 2010 and 2016 or closest available year Fig 5.5. Percentage of the population living on less than $ 5.50 per day (at 2011 international prices) in countries and territories with available data, 2000, 2010 and 2017 or closest available year Fig 5.6. Cost of covering the poverty gap in selected countries in the Region, 2019 and 2020 (current US$ million) Fig 5.7. Share (%) of pre-tax national income for richest 10%, middle 40% and bottom 50% of the population, by region, 2019 Fig 5.8. Share (%) of pre-tax national income held by the richest 1% of the population, by region, 1990–2019 Fig 5.9. Share (%) of income held by the top 10% in the Middle East and other regions, 1990–2016
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Fig 5.10. Share (%) of pre-tax national income for the richest 10%, middle 40% and bottom 50% of the population in countries and territories in the Region with comparable data available, 2019 Fig 5.11. Share of national income for the richest 10%, middle 40% and bottom 50% of population in Tunisia, 2000– 2019 Fig 5.12. Total tax revenue as a percentage of GDP and GDP per capita ( constant 2017 international $) in countries with available data, 2017 or latest available year Fig 5.13. Countries in the Region with tax revenue above 10% of GDP, 2000–2018 Fig 5.14. Countries in the Region with tax revenue below 10% of GDP, 2000–2018 Fig 5.15. Top marginal income tax rates in selected countries in the Region, 1979–2002 Fig 5.16. Share of all social protection and labour benefits relative to per capita household income or consumption, by region, 2008–2018 Fig 5.17. Coverage of social protection and labour programmes (% of population) in countries and territories in the Region with available data, 2015 or latest available year Fig 5.18. Coverage of social safety net programmes (% of population) in countries and territories in the Region with available data, 2017 or latest available year Fig 5.19. SPFI (as a percentage of GDP) in selected countries in the Region, by minimum income level, 2018 Fig 5.20. Expenditure on health care and military, and the ratio of total health care to military expenditure, by region (based on 11-year mean), 2001–2011 Fig 5.21. Expenditure on health care, military and education (as percentage of GDP) in countries and territories in the Region, 2019 or latest available year Fig 5.22. Expenditure on unhealthy food marketing in selected countries in the Region, 2009–2012 Fig 5.23. Net ODA received per capita by country in the Region (current US$), 2018 Fig 5.24. ODA in Kuwait, Saudi Arabia and United Arab Emirates on a grant equivalent basis and as a percentage of GNI, 2018 and 2019 Fig 5.25. DAH from the Middle East and North Africa, by recipient, 2000–2017
Tables Table 5.1. Size of tax evasion in selected countries and territories in the Region Table 5.2. Tax lost to corporate tax abuse annually in selected countries in the Region, 2020 Table 5.3. Cash transfer programmes in selected countries in the Region Table 5.4. Implementation of the WHO recommendations in the Region (compilation of responses to questionnaires in 2013, 2015 and 2017) Table 5.5. Total DAH received by country (US$ million) and the percentage received from the Middle East and North Africa region, 2017
Boxes Box 5.1. Minimum wage policy in Qatar Box 5.2. Wealth distribution in Tunisia Box 5.3. ESCWA 2020, policy brief 7 – a solidarity tax to address the impact of COVID-19 on poverty in the Arab region Box 5.4. Social and economic development in Saudi Arabia Box 5.5. Social protection programmes in the Region Box 5.6. Marketing unhealthy foods to children, Oman Box 5.7. Tobacco industry tactics in the Region Box 5.8. Tobacco control in the Islamic Republic of Iran and Saudi Arabia Box 5.9. Sugar-sweetened beverages tax in GCC countries
LIST OF FIGURES, TABLES AND BOXES
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CHAPTER 6: CULTURE AND SOCIETY
Figures Fig 6.1. Mean Gender Inequality Index, by region, 2018 Fig 6.2. Gender Inequality Index, by country, 2018 Fig 6.3. GEM scale score in Egypt by sex and wealth, 2016 Fig 6.4. GEM scale score in Egypt by sex and education level, 2016 Fig 6.5. GEM scale score in Egypt by sex and residence, 2016 Fig 6.6. GEM scale score in Egypt by sex and age group, 2016 Fig 6.7. GEM scale score in Lebanon by sex and wealth index, 2016 Fig 6.8. GEM scale score in Lebanon by sex and education, 2016 Fig 6.9. GEM scale scores in Lebanon by sex and employment position, 2016 Fig 6.10. GEM scale score in Lebanon by sex and age group, 2016 Fig 6.11. Hours per day spent on unpaid care work, by gender and region, 2014 Fig 6.12. Percentage of respondents in Egypt, Morocco and occupied Palestinian territory who agree that a woman’s most important role is to take care of the home and cook for the family, by gender, 2016 Fig 6.13. Percentage of women who have experienced physical and/or sexual violence from an intimate partner at some time in their life in selected countries in the Region, 2019 or latest available year Fig 6.14. Percentage of currently married women who have experienced physical, sexual, or psychological violence from most recent husband ever or within the past 12 months in Egypt, by wealth quintile, 2005 Fig 6.15. Percentage of currently married women who have experienced physical, sexual, or psychological violence from most recent husband ever or within the past 12 months in Egypt, by education level, 2005 Fig 6.16. Percentage of women who agree that a husband/partner is justified in beating his wife/partner under certain circumstances in selected countries and territories in the Region, 2019 or latest available year Fig 6.17. Percentage of women who agree that a husband is justified in hitting or beating his wife for at least one specific reason in selected countries in the Region, by education level, latest available year Fig 6.18. Opinions on having immigrants or foreign workers as neighbours, by selected country and territory in the Region, 2016 and 2019
Tables Table 6.1. Percentage who “strongly dislike” or “dislike” having immigrants or foreign workers as neighbours, by selected country and territory in the Region and by sociodemographic factor (2018/2019)
Boxes Box 6.1. Alcohol use and religion Box 6.2. FGM and religion Box 6.3. Reduction of FGM in Egypt: a collaborative effort between religious leaders, United Nations agencies and WHO Box 6.4. Reproductive health and family planning in Islamic Republic of Iran, Syrian Arab Republic and Yemen Box 6.5. Islamic Advisory Group for Polio Eradication Box 6.6. Religious leaders promoting female education in Afghanistan Box 6.7. WFP collaboration with the Aga Khan Development Network in Syrian Arab Republic and Muslim Hands in Somalia Box 6.8. Establishing partnerships between UNICEF and Al-Markaz al-Islami to improve social determinants of health in Jordan Box 6.9. WHO report on the prevalence and health effects of intimate partner and non-partner sexual violence
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Box 6.10. Impact of cash assistance programmes on the prevention and mitigation of, and response to, sexual and gender-based violence in Lebanon, 2017–2018 Box 6.11. Programmes in Pakistan to address gender-based violence Box 6.12. Work by WHO to strengthen the capacity of health systems to respond to gender-based violence in the Region Box 6.13. Measures to address gender-based violence during the COVID-19 pandemic in the Region Box 6.14. Attitudes to refugees Box 6.15. Gulf Cooperation Council policy on the employment of foreign domestic workers Box 6.16. The Safarni community cohesion intervention in Egypt
CHAPTER 7: THE NATURAL ENVIRONMENT AND HEALTH EQUITY
Figures Fig. 7.1. Effects of weather shocks on Moroccan farmers, by lowest and highest income quintile, 2009–2010 Fig. 7.2. Greenhouse gas emissions (million tonnes) by region, 2000–2017 Fig. 7.3. Greenhouse gas emissions (million tonnes) in the Region, by country, 2000–2017 Fig. 7.4. Annual CO2 emissions per capita (million tonnes) in the Region, 2000–2016 Fig. 7.5. CO2 emissions by sector (percentage of total fuel combustion) in the Region, 2014 Fig. 7.6. Greenhouse gas emissions (million tonnes) in the Region, by sector, 2000–2018 Fig. 7.7. Electricity production from fossil fuels, nuclear and renewables (terawatt-hours) in countries and territories in the Region, 2019 Fig. 7.8. Share of electricity production from renewables in selected countries in the Region, 2010–2018 Fig. 7.9. Share of benefits from gasoline subsidies in selected countries in the Region, by income quintile, 2014 Fig. 7.10. Share of benefits from electricity subsidies in selected countries in the Region, by income quintile, 2014 Fig. 7.11. Projected trends in renewable water resources per capita (cubic metres) for 19 countries and territories in the Region, 2020–2050 Fig. 7.12. Renewable water resources per capita (cubic metres) in the Middle East and North Africa, 2014 Fig. 7.13. Tree cover net gain/loss (per thousand hectares) in selected countries in the Region, 2000–2019
Tables Table 7.1. Projected impacts of climate change on health and health equity in the Region, by 2050 Table 7.2. NDC mitigation target pledges
Boxes Box 7.1. Oil prices and the COVID-19 pandemic Box 7.2. Adaptation and mitigation measures Box 7.3. Strategies to support renewable energy in the Region Box 7.4. Solar power and health in Morocco Box 7.5. Health systems and climate change Box 7.6. Unsafe water supply in Yemen Box 7.7. Unsafe water in Gaza Strip Box 7.8. Reducing water scarcity and improving health in Jordan Box 7.9. Fighting desertification in Tunisia Box 7.10. Locust swarms Box 7.11. Acting early in natural disasters
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CHAPTER 8: EQUITY IN MATERNAL AND CHILD HEALTH, THE EARLY YEARS AND EDUCATION
Figures Fig. 8.1. Maternal mortality ratio by country and territory in the Region, 2000–2017 Fig. 8.2. Antenatal care coverage (at least four visits) in selected countries in the Region, by wealth quintile, 2013–2017 Fig. 8.3. Percentage of births attended by skilled health personnel (doctor, nurse or midwife) in selected countries and territories in the Region, by poorest and richest wealth quintile, 2011–2019 Fig. 8.4. Percentage of births attended by skilled health personnel (doctor, nurse or midwife) in selected countries in the Region, by maternal education, 2013–2017 Fig. 8.5. Prevalence of anaemia in women of reproductive age in countries in the Region, 1990–2016 Fig. 8.6. Prevalence of anaemia among women of reproductive age in Sudan, by income and education level, 2016 Fig. 8.7. Percentage of women (aged 20–24 years) who were first married or in a union before the age of 15 or 18 in selected countries and territories in the Region, 2010–2018 Fig. 8.8. Adolescent fertility rate (births per 1000 girls aged 15–19 years) in countries and territories in the Region, 2014–2019 Fig. 8.9. Adolescent fertility rate (births per 1000 girls aged 15–19 years) in selected countries in the Region, by maternal education, 2003–2017 Fig. 8.10. Adolescent fertility rate (births per 1000 girls aged 15–19 years) in selected countries in the Region, by wealth quintile, 2003–2017 Fig. 8.11. Adolescent fertility rate (births per 1000 girls aged 15–19 years) in the Islamic Republic of Iran, Middle East and North Africa (average) and the world (average), 1960–2018 Fig. 8.12. Demand for family planning met by modern contraceptive methods in countries and territories in the Region, 2020 Fig. 8.13. Demand for family planning met by modern contraceptive methods in selected countries in the Region, by wealth quintile, 2013–2017 Fig. 8.14. Prevalence of social reproductive health risk factors in Jordan, by wealth quintile, 2017 Fig. 8.15. Under-5 mortality rate (deaths per 1000 live births) in selected countries in the Region, by wealth quintile, 2014–2018 Fig. 8.16. Under-5 mortality (deaths per 1000 live births) in Sudan, by state, 2014 Fig. 8.17. Neonatal, infant and under-5 mortality (deaths per 1000 live births) in Jordan, by nationality, 2017 Fig. 8.18. Prevalence of low-birth-weight newborns in countries and territories in the Region, 2014–2018 Fig. 8.19. Prevalence of low-birth-weight newborns (< 2.5 kg) in selected countries in the Region, by maternal education, 2013–2017 Fig. 8.20. Prevalence of exclusive breastfeeding among children under 6 months in countries and territories in the Region, 2014–2019 Fig. 8.21. Prevalence of stunting in children in countries and territories in the Region, 2014–2019 Fig. 8.22. Global and regional trends in and projections for the prevalence of stunting, by WHO region, 1990–2030 Fig. 8.23. Prevalence of wasting in children aged under 5 in selected countries in the Region, by wealth quintile, 2003–2018 Fig. 8.24. Prevalence of child malnutrition risk factors in Jordan, by maternal education, 2017 Fig. 8.25. Performance of infant health services in providing postnatal care in Jordan, by maternal education, 2017 Fig. 8.26. Full immunization coverage of 1-year-old children in selected countries in the Region, by maternal education, 2003–2015 Fig. 8.27. Performance of child health services in providing vaccination and health care in Jordan, by maternal education, 2017
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Fig. 8.28. Percentage of children (aged 36–59 months) developmentally on track in selected countries in the Region, by sex, 2012–2018 Fig. 8.29. Percentage of children (aged 36–59 months) provided early stimulation and responsive care in selected countries in the Region, by sex, 2009–2018 Fig. 8.30. Percentage of children (aged 0–4 years) experiencing at least four developmental activities in selected countries and territories in the Region, by wealth quintile, 2006–2012 Fig. 8.31. Enrolment in pre-primary education in selected countries and territories in the Region, by sex, 2017–2019 Fig. 8.32. Pre-primary school enrolment in selected countries and territories in the Region, 2010–2018 Fig. 8.33. Enrolment in early care and education in selected countries and territories in the Region, by wealth quintile, 2006–2012 Fig. 8.34. Enrolment in early childhood education (ages 3–5 years) in Jordan, by maternal education, 2017 Fig. 8.35. Primary school completion rates in selected countries and territories in the Region, by geographical residence, 2011–2018 Fig. 8.36. Primary school completion rates in selected countries and territories in the Region, by wealth quintile, 2011–2018 Fig. 8.37. Completion of lower secondary school in selected countries and territories in the Region, by wealth quintile, 2013–2018 Fig. 8.38. Completion of secondary school in selected countries and territories in the Region, by sex, 2013–2018 Fig. 8.39. Completion of secondary school in selected countries and territories in the Region, by geographical residence, 2013–2018 Fig. 8.40. Young people (aged 15–24 years) outside education, training or employment in selected countries and territories in the Region, by sex, 2014–2017 Fig. 8.41. Young people (aged 15–24 years) enrolled in vocational education in selected countries and territories in the Region, by sex, 2012–2019 Fig. 8.42. Enrolment in tertiary education in countries and territories in the Region, 2011–2019 Fig. 8.43. Proportion of adults (aged 25–59 years) receiving a higher education in Egypt, Jordan and Tunisia by maternal education, 2010–2014 Fig. 8.44. Proportion of adults (aged 25–59 years) receiving a higher education in Egypt, Jordan and Tunisia, by paternal education, 2010–2014 Fig. 8.45. Estimated number of universities in countries and territories in the Region, 2020 Fig. 8.46. Gross enrolment ratio for tertiary education in countries and territories in the Region, by sex, 2011–2019 Fig. 8.47. Tertiary education gross attendance ratio for women in selected countries and territories in the Region, by wealth quintile, 2004–2018 Fig. 8.48. Tertiary education gross attendance ratio for men in selected countries and territories in the Region, by wealth quintile, 2004–2018 Fig. 8.49. Achievement of at least a minimum proficiency in reading among students completing lower secondary education in selected countries in the Region, 2018 Fig. 8.50. Achievement of at least a minimum proficiency in mathematics among students completing lower secondary education in selected countries and territories in the Region, 2015 Fig. 8.51. Reading performance scores at age 15 years in selected countries in the Region, by wealth quartile, 2018 Fig. 8.52. Government expenditure on education as a percentage of total government expenditure in countries in the Region, 2006–2019 Fig. 8.53. Total government expenditure on education as a percentage of GDP in countries and territories in the Region, 2006–2019
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Boxes Box 8.1. Maternal, newborn and child health in Jordan Box 8.2. Postnatal care in the Gaza Strip Box 8.3. Reducing maternal and neonatal mortality in Afghanistan Box 8.4. Action against anaemia in Egypt Box 8.5. Community health workers in Pakistan Box 8.6. Improving maternal and neonatal health in Yemen Box 8.7. Improving family planning and adolescent fertility rates in the Islamic Republic of Iran Box 8.8. Family planning services in rural Jordan Box 8.9. Shifting attitudes to sexual and reproductive health in Tunisia Box 8.10. Breastfeeding in Sudan: educating staff, mothers and families Box 8.11. International Code of Marketing of Breast-milk Substitutes Box 8.12. Reducing malnutrition in Morocco Box 8.13. Improving incomes and nutrition in the Syrian Arab Republic Box 8.14. Nutrition and health in Somalia Box 8.15. Integrated Management of Childhood Illness Box 8.16. Supporting refugee parents in Lebanon and Jordan Box 8.17. Early education in rural Pakistan Box 8.18. Primary schools in the occupied Palestinian territory Box 8.19. Educating refugee children in Jordan and Lebanon Box 8.20. Continuing education during COVID-19 in Yemen Box 8.21. Inclusive and equitable education in occupied Palestinian territory Box 8.22. Monitoring school attendance: Out-of-School Children Initiative Box 8.23. Active labour market programmes for young people in Egypt Box 8.24. Universities helping start-ups
CHAPTER 9: WORKING LIVES AND HEALTH EQUITY
Figures Fig. 9.1. Total unemployment as a percentage of total labour force (modelled ILO estimate), by region, 2000–2019 Fig. 9.2. Employment to population ratio (age 15 years and older) total (%) (modelled ILO estimate) in countries and territories in the Region, 2000–2019 Fig. 9.3. Share of public sector employment among educated new entrants to the labour force in Egypt, Jordan and Tunisia, 1975–2015 Fig 9.4. Informal employment, including agriculture, as a percentage of total employment, by region, 2016 Fig. 9.5. Annual growth rates in informality according to the Schneider Index, by region, 2000–2007 Fig. 9.6. Informal employment as a percentage of total employment in selected countries and territories in the Region, 2011–2019 Fig. 9.7. Proportion of the labour force (%) not contributing to social security in selected countries in the Middle East and North Africa, 2000–2007 Fig 9.8. Vulnerable employment in the Middle East and North Africa and the world, by gender, 1990–2018 Fig 9.9. Employment to population ratio (ages 15 years and older) (%) (modelled ILO estimate) in the Region and the world, by gender, 2000–2020 Fig 9.10. Female labour force participation rate (percentage of female population aged 15 years or older) (modelled ILO
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estimate) in Saudi Arabia, 2011–2020 Fig. 9.11 Employment to population ratio(ages 15 years and older) female (%) (modelled ILO estimate) in countries and territories in the Region, 2000–2019 Fig 9.12. Unemployment, total and youth (15–24 years) (% of total labour force) (modelled ILO estimate), by region, 2019 Fig. 9.13. Youth unemployment, total (15–24 years) (% of total labour force) (modelled ILO estimate) in countries in the Region, 2000–2020 Fig. 9.14. Youth unemployment rates in selected countries and territories in the Region, by sex, 2012–2015 Fig 9.15. Working poverty rate (percentage of employed living below US$1.90 PPP) in selected countries in the Region Fig. 9.16. Wage equality for similar work (female to male ratio) in selected countries in the Region, 2014 and 2018 Fig 9.17. Proportion of wage earners (%) residing in countries where no minimum wage exists, by region and the world, 2020 Fig. 9.18. Fatal occupational injury rate (per 100 000 workers) in selected countries and territories in the Region, latest available year Fig. 9.19. Non-fatal occupational injury rate (per 100 000 workers) in selected countries and territories in the Region, latest available year Fig 9.20. Distribution (%) of work-related injuries and case fatalities according to type of work in Qatar, 2010–2012 Fig 9.21. Health problems experienced by Nepalese female migrant workers in the Middle East and Malaysia, 2009– 2014 Fig 9.22. Distribution of foreign labour in selected GCC countries, by education level, 2006 Fig 9.23. Estimated prevalence of modern slavery (per 1000 population) by region, 2018 Fig 9.24. Estimated prevalence (victims per 1000 population) of modern slavery in countries in the Region, 2018 Fig 9.25. Percentage of victims of forced labour exploitation who are held in debt bondage, by sex and ILO region Fig 9.26. Means of coercion and exploitation (%) experienced by victims of trafficking Fig 9.27. Percentage of children (aged 5–17 years) engaged in child labour (economic activities) in selected countries in the Region, 2012–2018 Fig 9.28. Minimum age for light work (% of countries), by region, 2016
Tables Table 9.1. Level of government-provided financial assistance that a minimum wage worker would likely be entitled to during unemployment in countries in the Region, 2012 Table 9.2. Proportion of unemployed receiving unemployment benefits in Bahrain, Islamic Republic of Iran and Tunisia Table 9.3. Legislation to prohibit sex-based discrimination in hiring and recruitment at work in countries in the Region Table 9.4. Impact indicators of the economic empowerment pillar of the National Strategy for the Empowerment of Egyptian Women 2030 Table 9.5. National youth policies/strategies and public institutions focused on youth in countries and territories in the Region, 2000–2015 Table 9.6. Domestic and/or agricultural workers excluded from minimum wage policies in the Region, 2020 Table 9.7. Employed covered by employment injury insurance and social protection (%) in the event of work injury in selected countries in the Region, 2017 Table 9.8. Non-fatal occupational injuries (per 100 000 workers) by migrant status in Qatar and Pakistan, 2016 and 2018 Table 9.9. ILO female migrant domestic worker surveys in Bahrain, Kuwait, Lebanon and United Arab Emirates, 2001–2002 Table. 9.10. Minimum age for admission to employment in countries in the Region, 2016
Boxes
LIST OF FIGURES, TABLES AND BOXES
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Box 9.1. COVID-19 and vulnerable workers Box 9.2. Efforts to regularize informal employment in Morocco and Tunisia Box 9.3. Female participation in the labour force in Saudi Arabia Box 9.4. Legislation and strategies for economic empowerment of women in Egypt Box 9.5. Youth employment programmes in Egypt and Tunisia Box 9.6. The impact of sanctions on employment Box 9.7. Minimum wage in the Egyptian Constitution Box 9.8. The rights of migrant workers in the United Arab Emirates Box 9.9. Health issues of Nepalese female migrant workers in the Middle East Box 9.10. Occupational injuries and diseases amongst Saudi and non-Saudi insured workers Box 9.11. The impact of heat stress on cardiac mortality in Nepali migrant workers in Qatar Box 9.12. ILO’s project to improve conditions for migrant domestic workers in the Middle East, December 2012–May 2015 Box 9.13. Action to protect and support victims of trafficking in the Middle East and North Africa Box 9.14. Child labour and the interruption of schooling among Syrian refugees in Lebanon Box 9.15. Efforts to combat child labour in Jordan, 2011
CHAPTER 10: HEALTHY AGEING
Figures Fig. 10.1. Percentage of total population aged 65 years and older, by region, 2000–2019 Fig. 10.2. Percentage of total population aged 65 years and older in countries and territories in the Region, 2000–2019 Fig. 10.3. Past and projected distribution of the population (%) in the Region, by age group, 1950–2050 Fig. 10.4. Percentage point increase in the population aged 65 years and older in countries and territories in the Region, between 2015–2030 and 2030–2050 Fig. 10.5. Old-age dependency ratio in countries and territories in the Region, 2009–2019 Fig. 10.6. Proportion of older adults with a disability in selected countries and territories in the Region, by age and sex, 2007–2020 Fig. 10.7. a) Educational attainment of males aged 60 years and older in selected countries and territories in the Region, 2015 Fig. 10.7. b) Educational attainment of females aged 60 years and older in selected countries and territories in the Region, 2015 Fig. 10.8. Attainment of a secondary-school education in adults aged 60 years and older in Egypt, Jordan and Tunisia, by sex and residence, 2010, 2012 and 2014 Fig. 10.9. Average household size in selected countries in the Region, 1990, 2000 and 2012 Fig. 10.10. Type and number of elderly care homes (per 100 000 people aged 60 years and older) in selected countries and territories in the Region, 2017 Fig. 10.11. Expenditure on public social protection for pensions and other benefits, excluding health, for older adults in selected countries in the Region, 2004–2016 Fig. 10.12. Proportion of the population above the statutory pension age who receive a pension in selected countries and territories in the Region, 2006–2015 Fig. 10.13. Income protections for elderly people, by region and type of income protection scheme, 2012 Fig. 10.14. Active contributors to a pension scheme in the working-age population (15–64 years) in selected countries in the Region, by sex, 2007–2015 Fig. 10.15. Estimated prevalence of elder abuse, by region and sex, 2017
Tables
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Table 10.1. Key policies, national strategies and programmes for healthy ageing in countries and territories of the Region, 2015 Table 10.2. Coverage of public pension schemes in countries and territories of the Region Boxes Box 10.1. Human rights and older people Box 10.2. Initiatives to support “ageing in place” in Tunisia Box 10.3. Policies and programmes to improve incomes for older people Box 10.4. Older migrant workers in the United Arab Emirates Box 10.5. Health needs and status of older refugees from the Syrian Arab Republic Box 10.6. Supporting older people in the Region Box 10.7. WHO support for age-friendly cities Box 10.8. Age-friendly cities in the Region Box 10.9. Middle East and North Africa Research on Ageing Healthy network Box 10.10. Work programmes for older people
CHAPTER 11: BUILT ENVIRONMENTS AND HEALTH EQUITY
Figures Fig. 11.1. Proportion of population (%) living in urban areas, by region, 2000–2019 Fig. 11.2. Proportion of population (%) living in urban areas in countries and territories in the Region, 2000–2019 Fig. 11.3. Distribution of licensed vehicles (%) by vehicle type in the West Bank, 2018 Fig. 11.4. Motor vehicles per 1000 population versus GDP per capita, by country in the Region, 2014 Fig. 11.5. Mode of transport use in Cairo, Egypt, 2010 and 2019 Fig. 11.6. Proportion of countries (%) with national and subnational policies supporting sustainable transport in the Region, 2013 and 2015 Fig. 11.7. Housing affordability (house price to income ratio) in selected countries in the Region, 2011 Fig. 11.8. Shortage of affordable housing (in thousands) in selected countries in the Region, 2018 Fig. 11.9. Proportion of urban population (%) living in slum households in selected countries in the Region, 2018 Fig. 11.10. Proportion of urban population (%) living in slum households in selected countries in the Region, 2014–2018 Fig. 11.11. Proportion of Syrian refugee households living in shelters that are overcrowded, below humanitarian standards and/or in dangerous condition in Lebanon, by housing type, 2019 Fig. 11.12. Prevalence of specific shelter conditions (%) among Syrian refugee households in Lebanon, 2019 Fig. 11.13. Proportion of population (%) with access to at least basic drinking water services, by region, 2000–2017 Fig. 11.14. Proportion of population (%) using at least basic drinking water services in countries and territories in the Region, 2000–2017 Fig. 11.15. Percentage of population with access to improved drinking water in countries and territories in the Region, 2017 Fig. 11.16. Percentage of population using safely managed drinking water services in selected countries in the Region, 2000–2017 Fig. 11.17. Coverage of drinking water (%) for households in countries and territories of the Region, by service level, 2017 Fig. 11.18. Coverage of drinking water (%) in WHO regions, by service level, 2017 Fig. 11.19. Proportion of working age population with access to improved sources of water in Somalia, 2017 Fig. 11.20. Drinking water services in Afghanistan, by wealth quintile, 2017
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Fig. 11.21. Proportion of population (%) with access to improved sanitation facilities in countries and territories in the Region, 2017 Fig. 11.22. Proportion of population (%) using at least basic sanitation services, by region, 2000–2017 Fig. 11.23. Proportion of population (%) using at least basic sanitation services in countries and territories in the Region, 2000-2017 Fig. 11.24. Proportion of population (%) using at least basic sanitation services in the Region, by residence, 2000– 2017 Fig. 11.25. Proportion of working age population (%) with access to improved sanitation in Somalia, 2017 Fig. 11.26. Proportion of population (%) using safely managed sanitation services in countries and territories in the Region, 2010-2017 Fig. 11.27. Proportion of population (%) with access to electricity, by region, 2000–2018 Fig. 11.28. Proportion of population (%) with access to electricity in countries and territories in the Region, 2000– 2018 Fig. 11.29. Percentage of urban and rural population with access to electricity in the Region, 2000–2018 Fig. 11.30. Percentage of individuals using the internet in countries and territories in the Region, 2000–2017 Fig. 11.31. Percentage of individuals using the internet at any frequency in selected countries and territories in the Region, by gender, 2018–2019 Fig. 11.32. Percentage of individuals using internet at any frequency in selected countries and territories in the Region, by residence, 2018–2019 Fig. 11.33. Proportion of population (%) with a household internet connection in selected countries and territories in the Region, by consumption per capita quintiles, 2012–2017 Fig. 11.34. Mortality rate attributed to ambient and household air pollution per 100 000 population (age-standardized) in countries in the Region, 2016 Fig. 11.35. Ambient and household air pollution attributable death rate, per 100 000 population (age-standardized), by country in the Region, 2016 Fig. 11.36. Percentage of the population with access to clean cooking in countries in the Region, 2017 Fig. 11.37. Proportion of population (%) using polluting fuels for cooking, by WHO region, 2016
Tables Table 11.1. Countries and territories in the Region with speed laws meeting best practices, 2017 Table 11.2. Application of United Nations vehicle safety standards in countries and territories of the Region, 2018 Table 11.3. WHO’s recommendations on housing and health, 2018 Table 11.4. Strategies and programmes to address informal settlements in selected countries and territories in the Region, 2020 Table 11.5. Countries and territories in the Region that recognize the human right to water and sanitation in constitutions or legislation, 2013–2014 Table 11.6. Sanitation and drinking water measures for those living in poverty in the Region, 2013–2014 Table 11.7. Average annual population-weighted PM2.5 concentrations in countries and territories in the Region, 2019 Table 11.8. Age-standardized death rates attributable to PM2.5 in countries and territories in the Region, 2019
Boxes Box 11.1. Examples of programmes and policies for sustainable urban development in the Region Box 11.2. Examples of programmes to improve transport systems in the Region Box 11.3. Housing conditions and health in a refugee camp in the occupied Palestinian territory Box 11.4. Upgrading slum areas in Egypt
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Box 11.5. Housing policies in Iraq from 2008 onwards Box 11.6. Housing conditions for migrants in GCC countries Box 11.7. WHO guidelines on housing and health Box 11.8. Affordability in the Egyptian housing market Box 11.9. Finances for housing in Tunisia Box 11.10. Refugees in informal settlements in Lebanon Box 11.11. Palestinians in refugee camps in the Region Box 11.12. Regularizing informal settlements in Iraq Box 11.13. Improving access to water and sanitation, Morocco Box 11.14. WASH strategies in Jordan Box. 11.15. An initiative for improving WASH services in Yemen Box 11.16. Somali Aid WASH programme Box 11.17. Programme to improve water, sanitation and hygiene for refugees in Lebanon Box 11.18. Commitments to eliminate inequities in WASH in Afghanistan, Pakistan and Sudan Box 11.19. Examples of waste management initiatives Box 11.20. COVID-19 pandemic and impact on air pollution
CHAPTER 12: HEALTH SYSTEMS FOR HEALTH EQUITY
Figures Fig. 12.1. Value of the UHC SCI by WHO region, 2000–2017 Fig. 12.2. Value of the UHC SCI in countries and territories in the Region, 2017 Fig. 12.3. Out-of-pocket expenditure as a percentage of current health care expenditure in countries in the Region, 2018 Fig. 12.4. Percentage of the population impoverished by out-of-pocket expenditure on health, by WHO region, 2015 Fig. 12.5. Catastrophic health spending (10% threshold) by WHO region, 2000–2015 Fig. 12.6 Catastrophic health spending (25% threshold) by WHO region, 2000–2015 Fig. 12.7. Proportion of the population (%) spending more than 10% and 25% of their household consumption or income on out-of-pocket health care expenditure in selected countries in the Region, 2015 or latest available year Fig. 12.8. Proportion of population (%) at risk of impoverishing expenditure when surgical care is required, by country with available data, 2020 or latest available year Fig. 12.9. Expenditure on health care (as a percentage of GDP) by region, 2000–2017 Fig. 12.10. Expenditure on health care per capita (US$) by region, 2000–2017 Fig. 12.11. Expenditure on health (as a percentage of GDP) in countries in the Region, 2018 Fig. 12.12. Public expenditure on health from domestic sources per capita (PPP, international $) in countries in the Region, 2017 or latest available year Fig. 12.13. Coverage of reproductive and maternal interventions in Afghanistan, 2003–2015 Fig. 12.14 Coverage of nutritional interventions in Afghanistan, 2002–2016 Fig. 12.15. Essential public health functions framework
Tables Table 12.1. Overview of primary health care in selected countries and territories in the Region, 2018 Table 12.2. Grouping of selected countries in the Region, according to their health promotion and education strategies, 2020
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LIST OF FIGURES, TABLES AND BOXES
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Box 12.1. Health promotion through primary health care Box 12.2. Impact of conflict on the health system in Yemen Box 12.3. Impact of conflict on the delivery of maternal and child health services in Afghanistan Box 12.4. Impacts of occupation on health systems in the occupied Palestinian territory Box 12.5. Behaviour change communication programme in Yemen Box 12.6. The Health Systems in Emergencies Lab in the Eastern Mediterranean Region Box 12.7. The Deliver Accelerated Results Effectively and Sustainably (DARES) collaboration Box 12.8. Access to health care for refugees and IDPs Box 12.9. WHO and country support in Afghanistan Box 12.10. The Sehatmandi Project in Afghanistan Box 12.11 Addressing obesity in Jordan using a social determinants of health approach Box 12.12. Pakistan’s National Health Vision 2016–2025
CHAPTER 13: GOVERNANCE AND TAKING ACTION TO BUILD BACK FAIRER
Figures Fig. 13.1. Percentage of population per freedom of expression category, by region, 2019 Fig. 13.2. Perceived freedom in expression of opinion, peaceful protest and ability to join associations in the Arab region, 2006–2019 Fig. 13.3. a) Perceived freedom of expression, by education Fig. 13.3. b) Perceived freedom to protest peacefully, by education Fig. 13.3. c) Perceived freedom to join associations, by education Fig. 13.4. World Press Freedom Index scores in the Region, by country and territory, 2020 Fig. 13.5. Civil society engagement in activities relating to the social determinants of health, 2019 Fig. 13.6. Average SDG Index score by WHO region, 2020 Fig. 13.7. SDG Index scores in the Region, by country, 2020 Fig. 13.8. Current assessment of progress on the SDGs in the Region, by country, 2020 Fig. 13.9. Average CPI score, by region, 2019 Fig. 13.10. CPI scores in the Region, by country, 2019 Fig. 13.11. Perceived extent of corruption within national state agencies and institutions, by selected country in the Region, 2018 Fig. 13.12. Percentage of respondents who think government is doing well or poorly at addressing corruption, by selected country in the Region, 2019 Fig. 13.13. Percentage of public service users who had paid a bribe in the past 12 months for services such as health care and education. by selected country in the Region, 2018–2019
Tables Table 13.1. Regional cooperation mechanisms Table 13.2. Status of ratification of the nine core international human rights treaties and their nine optional protocols in the Region, by country, 2021
Boxes
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Box 13.1. Principles and actions for the Region Box 13.2. Principles for governance to build back fairer for health equity Box 13.3. Examples of HiAP in the Eastern Mediterranean Region Box 13.4. Taking action to build back fairer to achieve greater health equity Box 13.5. Do something, do more, do better – developing national action plans for health equity Box 13.6. Examples of national plans to “do something, do more, do better” Box 13.7. Perceptions and experience of civil society organizations in social determinants of health – regional survey results Box 13.8. Examples of service delivery by civil society organizations in the Region Box 13.9. Regional consultation to enhance the role of civil society organizations in the health and sustainable development agenda in the Region, 2015 Box 13.10. Measuring social return on investment in Oman Box 13.11. MSF – improving health and the causes of health inequities Box 13.12. Reducing inequities in Egypt through population health systems Box 13.13. Improving health equity in Tehran Box 13.14. Inclusive and child-friendly cities in the Region Box 13.15. Policy context related to health and the SDGs in Egypt and Jordan Box 13.16. The Regional Health Alliance Box 13.17. Documenting human rights violations in the Eastern Mediterranean Region Box 13.18. Examples of anti-corruption initiatives in the Region
LIST OF FIGURES, TABLES AND BOXES
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NOTE FROM THE CHAIR
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The experience of countries and territories within the Eastern Mediterranean Region of the World Health Organization (WHO) shows that ill health is not destiny. Health of populations can improve remarkably rapidly. Where such improvements have taken place, it is not only access to quality medical care that has played an important part, but improvement in the conditions in which people are born, grow, live, work and age, and in the structural drivers of those conditions. In other words, there has been improvement in the social determinants of health. Tragically, in populations whose lives have been disrupted by armed conflict and forced movement, or by increases in poverty and hunger, health can deteriorate quickly, too. Further, amid the welcome improvements in health in the Region, there are marked differences in health within and between countries. Much of these differences between social groups are judged to be avoidable, hence they are labelled health inequities. Putting them right is a matter of social justice.
It is to address these systematic health inequities that the WHO Regional Director for the Eastern Mediterranean, Dr Ahmed Al-Mandhari, set up the Commission on Social Determinants of Health for the Eastern Mediterranean Region. There are two types of challenge that we have had to face. The first and most obvious is the structural causes of health inequities in the Region: violent conflict, mass movement of peoples, gender inequity, social and economic inequities, climate change and extreme environments, and religious frictions. These are not so much barriers to our work, but the reasons for pursuing it – to respond to these critical challenges to health. The second type of challenge is the dearth of evidence from the Region on what actions on social determinants of health work to make a difference, to improve health equity. Indeed, a core part of our recommendations is for better data systems for monitoring and evaluation, and for a research agenda to fill in important gaps in knowledge. That said, gaps in knowledge are not unique to the Eastern Mediterranean Region. The task we set ourselves as a Commission was to use the best evidence from the Region, and globally, to inform judgements on what needs to be done.
A report of this nature and length may appear daunting. Ministers of health may conclude that our recommendations lie outside their areas of jurisdiction. Most of our recommendations are for the conditions in which people are born, grow, live, work and age, and the structural drivers of those conditions. The implications
are clear: ministers of health may play a leadership role, but it is for the whole of government, and society, to act. And not just national governments. – there is much that city and regional governments can do. We have also recommended actions for civil society and faith- based organizations, and for multinational organizations, including WHO and other members of the United Nations family.
The report may appear daunting, too, because it concludes that so much needs to be done in so many domains. Where to start? It is not the length of the report that represents the scale of our ambition, but the breadth of areas that we cover. Simply put, our ambition is to lay the basis for achieving better societies that would lead to greater equity of health and well-being. Chapters 4 to 13 set out entry points, and concrete steps, for relevant parts of government, and other actors to achieve this ambition. We lay out the evidence, the principles of action and the domains in which action needs to take place. The precise nature of those steps needs to be elaborated within each country. Given the sheer diversity of the Region, one formula will not apply. We see this not as a threat but as an opportunity. It is vitally important that countries do the work to turn these recommendations into context- specific policies and practice.
Working with a wonderful group of Commissioners, and committed staff at the WHO Regional Office for the Eastern Mediterranean, has been an exciting journey. It is part of a global movement for health equity, which requires action on social determinants of health, in addition to progress towards universal health coverage. We do not see this report as the end of the journey, but as a step along the way. The next steps will involve commitment of countries, involvement of WHO and international organizations, cooperation and sharing of experience – to be full partners of the global health equity movement.
The Commission was formed before the COVID-19 pandemic affected the world. And the effect of the pandemic on inequities gave extra urgency to our work. The pandemic also presents an opportunity, as countries emerge from its consequences: to build back fairer.
Michael Marmot Chair, Commission on Social Determinants of Health in the Eastern Mediterranean Region
THE COMMISSIONERS
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Michael Marmot University College London, London, United Kingdom of Great Britain and Northern Ireland
Rowaida Al-Maaitah Jordan University of Science and Technology, Amman, Jordan
David Bishai Johns Hopkins University, Baltimore, United States of America
Abdirizak Ahmed Dalmar Somali Disaster Resilience Institute, Mogadishu, Somalia
Rajae El Aouad Hassan II Academy of Sciences and Technology, Rabat, Morocco
Assad Hafeez Health Services Academy, Islamabad, Pakistan
Senait Fisseha Susan Buffet Foundation, Omaha, United States of America
Stephen Gloyd University of Washington, Seattle, United States of America
Bagher Larijani Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
Salwa Najjab Juzoor for Health and Social Development, Jerusalem, occupied Palestinian territory
Iman Nuwayhid American University of Beirut, Beirut, Lebanon
Hoda Rashad American University of Cairo, Cairo, Egypt
K. Srinath Reddy Public Health Foundation of India, New Delhi, India
Anita Zaidi Bill & Melinda Gates Foundation, Seattle, United States of America
Adel El Zayani Human and Environment Affairs, Gulf Cooperation Council
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INTRODUCTION TO THE COMMISSION
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INTRODUCTION TO THE COMMISSION
BUILD BACK FAIRER
“Build back fairer” is the title we have given to this report of the Commission on Social Determinants of Health in the Eastern Mediterranean Region. The COVID-19 pandemic has exposed underlying inequities in health within and between countries all over the world, and it has also amplified them. The necessary societal response to the pandemic has made inequities worse. The title of this report reflects our judgement that, as countries emerge from the pandemic, it is not desirable to attempt to reconstruct the status quo. Rather, this is a moment to work towards more socially just societies. In an alternative world where there had been no pandemic, there would still have been great need for evidence-based policies to reduce inequities in health within and between countries. In half of the countries in the Eastern Mediterranean Region, the “back” of build back fairer could apply to recovery from conflict, or the related challenges of mass movement of people. Whether recovering from the pandemic, from conflict, or facing the looming economic and environmental crises, there is a need to use the best evidence, in a spirit of social justice, to create fairer societies.
Our commitment to build back fairer is not some abstract political or philosophical concern, but is driven by a concrete focus on health equity. Creating the conditions that will enable all residents of the Region to lead lives of dignity will lead to better health for all and a fairer distribution of health – greater health equity. To achieve this goal, action is needed on the social determinants of health: the conditions in which people are born, grow, live, work and age; and what we label the structural drivers of those conditions – political, economic, cultural and environmental influences.
Universal health coverage is of vital importance, and health systems are necessary for treating illness when it occurs. But it is social determinants that shape health, and inequities in health, in the first place. The WHO Commission on Social Determinants of Health asked: why treat people and send them back to the conditions that made them sick? It is the conditions that make people sick and deprive them of the opportunity to lead lives of dignity that is our focus.
There are several features of health in the Eastern Mediterranean Region, in addition to COVID-19, that lend urgency to the actions that we lay out here.
The first challenge is the sheer magnitude of health inequities. Among women, life expectancy ranges from 59 years in Somalia to 84 years in Kuwait; among men, it ranges from 54 to 79 years in the same countries. Based on figures such as these, and others discussed below, the United Nations Development Programme (UNDP) classifies some countries in the Region as very highly developed, some as low human development, and others at points in between. We meet this challenge by saying:
• Do something – for countries at a low level of human development, taking some action to improve the conditions of life can have a big impact on health.
• Do more – countries that are already taking action on the social determinants of health can do more.
• Do better – countries with very high levels of development can always do better.
There are also marked health inequities within countries. The most reliable figures for within-country inequities come from the beginning of life. In Sudan, for example, the worst-off state has an under-5 mortality rate of 112 deaths per 1000 live births, while in the
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best-off state the rate is 30. The aim is first to reduce this within-country inequity. However, an under-5 mortality rate of 30 deaths per 1000 live births is far from desirable, and between-country analysis shows what should be the aim for all countries – to achieve the best rate in the Region, which is 7 deaths per 1000 live births for Qatar.
A second major challenge in the Region is the large number of fragile and conflict-affected countries. Ten out of 36 countries and territories in the World Bank’s Harmonized List of Fragile Situations (2019) are in the Region (1). Life expectancy in these countries is nine years lower than the global average, providing a marker of global inequities and socioeconomic challenges. People living in fragile and conflict-affected situations and emergency settings are at greater risk of experiencing all the disadvantages associated with the social determinants of health; and it is the poorest who suffer the most.
The third challenge, linked to conflict, is the mass movement of people, including both international refugees and internally displaced persons (IDPs). These conflict-associated movements are in addition to economic migration.
Fourth are the problems that affect every region – poverty, unemployment, economic inequity and weak mechanisms for redistribution, concentration of wealth at the top, and corporate practices which harm health. These challenges are particularly prevalent in the Eastern Mediterranean Region, and they are likely to be made worse by COVID-19 and the societal response to the pandemic.
Fifth, culture, religion and political considerations are potent drivers of the conditions for health in the Region, both for ill – conflict, migration and gender inequity – and for good, when religion and civil society harness their influence to support health and health equity. Respect for human rights and legal mechanisms can make an important difference to the possibility of living a dignified life, and hence to health and health equity. Shifting gender norms and attitudes towards refugees and IDPs can be supported by legal mechanisms.
The sixth major challenge, looming over health in every region of the world, is the climate crisis and degradation of the natural environment. As we use the best evidence to map out recommendations to build back fairer, it is of utmost importance that these go along with action on climate change and protection of natural environments – for sustainable health equity. The Sustainable Development Goals (SDGs) provide a ready framework for such action.
THE COMMISSION: AIMS AND OBJECTIVES
In 2019, Dr Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean, established the independent, expert Commission on Social Determinants of Health in the Eastern Mediterranean Region. Our aim is to establish a comprehensive evidence base on health inequities in the Eastern Mediterranean Region and the factors that drive such inequities; and assess practical ways of addressing them within the context of the Member States of the Region, including those facing conflict and emergencies.
The Commission has five objectives.
1. Analyse and present existing data on health inequities and social determinants of health, including conflict, in the Eastern Mediterranean Region context.
2. Document actions being taken by international organizations, governments, nongovernmental organizations, civil society and communities to address these issues.
3. Build knowledge and evidence for action and offer practical, specific recommendations to reduce health inequities.
4. Provide strategic guidance on developing plans for equity including governance and monitoring systems for health equity.
5. Identify opportunities to build capacity through research and evaluation of health inequities and programmes for action, and establish knowledge networks across the Eastern Mediterranean Region.
The inequitable impacts of the COVID-19 pandemic required another, additional, objective for the Commission:
6. Describe and make proposals to mitigate the health inequity impacts arising from COVID-19, including infection, mortality and the long-term impacts of containment measures.
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Data and information specific to all the countries and territories of the Region are not available for every indicator and topic included in this report. We have, therefore, sometimes drawn on other relevant regional groupings. Where possible in such cases, we have extracted data for countries of the Eastern Mediterranean Region only, but in some cases the data are available only at the level of an alternative regional grouping.
The other regional groupings included in the report are:
• The Middle East and North Africa region: Algeria, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Malta, Morocco, occupied Palestinian territory, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen (3).
Fig. 1.1. The WHO Eastern Mediterranean Region
Fig. 1.1 shows the WHO Eastern Mediterranean Region, which is the geographical focus of this report. The Region consists of 21 WHO Member States and the occupied Palestinian territory, including east Jerusalem (2). Specifically, it includes Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, occupied Palestinian territory, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen (2).
Yemen
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Sudan
Islamic Republic of Iran
Iraq
Libya
Syrian Arab Republic
Pakistan
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United Arab Emirates
Kuwait Jordan
Egypt Saudi Arabia
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Disclaimer: The presentation of material on the maps contained herein does not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or areas or its authorities of its frontiers or boundaries Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
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• The Near East and North Africa region: Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Qatar, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen (4).
• Gulf Cooperation Council (GCC) countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates (5).
• Arab countries: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, occupied Palestinian territory, Oman, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen (6).
• Western Asia region: Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, occupied Palestinian territory, Oman, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates and Yemen (7).
The report assesses the available disaggregated data. This mainly includes international survey data on maternal and child health and education which are available for some countries with lower levels of development, national data where available, and available disaggregated data from monitoring the SDGs. Academic studies, surveys and qualitative data were also drawn on. In general, there is a lack of quality disaggregated data from countries and territories in the Eastern Mediterranean Region, which hinders monitoring of health indicators and inequities in health. One of the most important recommendations from this Commission is greater investment in national data systems capable of monitoring health and inequities in key social determinants and the development of reliable, regular surveys.
This Commission has also drawn on evidence and reports generated from international organizations including United Nations agencies and the World Bank, regional organizations, and data repositories including Our World in Data, World Bank databases, the WHO Global Health Observatory data repository, the United Nations Children’s Fund (UNICEF) Data Warehouse, the World Inequality Database, the United States Agency for International Development (USAID) STATcompiler and the Arab Barometer. National reports on policies and strategies have been assessed, and we refer to relevant studies and reports from academic institutions.
Throughout the report we include case-studies of policies and programmes relevant to the areas we cover; these include national and international policies and programmes, civil society programmes, and interventions by humanitarian and aid agencies.
Where available, we have included evaluation evidence. However, in many cases, evaluations have not been undertaken and we report that action has taken place without being able to report on impact. These case-studies may serve as guidelines for what to do – or what not to do – to improve health equity, and act as encouragement and support for a range of stakeholders to take action.
SOCIAL DETERMINANTS OF HEALTH AND HEALTH EQUITY
The Commission on Social Determinants of Health in the Eastern Mediterranean Region builds on the global WHO Commission on Social Determinants of Health, 2005–2008 (8) and subsequent regional commissions in Europe (9) and the Americas (10) which analysed the role and extent of social determinants in producing health inequities within and between countries. These commissions explained how action on the social determinants can reduce health inequities, as well as improving outcomes in other areas which are positive for development – education, employment, community cohesion and reduction of crime.
The report of the global WHO Commission on Social Determinants of Health set out the evidence that inequities in health – avoidable health inequalities – arise because of the circumstances in which people are born, grow, live, work and age. These conditions are shaped by political, social and economic forces – inequities in power, money and resources. The Commission proceeded from the view that a society can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill health.
We use the language of social determinants of health, following the WHO Commission on Social Determinants of Health. We use “social determinants” as an umbrella term to include “structural” drivers – political, cultural, economic and commercial, and the social aspects of environmental determinants of health – and the conditions of daily life. We have little interest in demarcation disputes as to where the boundaries lie between social determinants of health and, for example, environmental determinants. Those of us concerned with social determinants of health need to work closely with the people and groups committed to improving the environment and dealing with the climate crisis; hence our conceptual framework laid out in the section below.
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The Commission on Social Determinants of Health in the Eastern Mediterranean Region further develops the approaches outlined by the previous commissions to ensure it is appropriate and specific to the Region
Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death … [T]here are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen.
Social injustice is killing people on a grand scale.
From: 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 (2008).
BUILDING BACK FAIRER AND HEALTH EQUITY: CONCEPTUAL APPROACH
The overarching framework of this Commission is social justice – putting equity of health and well- being at the heart of all policies and programmes by national government, local government, international organizations, and civil society. Creating the opportunities for people to lead dignified lives will lead to better health and greater health equity.
The conceptual framework for the Commission sets out how structural drivers affect the conditions of daily life which produce health and stark health inequities across
the Eastern Mediterranean Region. Access to health care is of course vital for health, but it is not the central focus of this Commission; we examine societal features outside health care which are largely responsible for shaping health. The conceptual framework is shown in Fig. 1.2.
The framework gives conceptual understanding. It also represents potential points of intervention and provides the structure for our report. In each of these areas, recommendations for action are made for a range of stakeholders and for countries at different levels of development.
and to immediate issues, including the impact of climate change, fragile and conflict-affected situations, refugees and migrants, and the COVID-19 pandemic.
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This Commission is well aware of the politics driving conflict and its consequences, including migration, sanctions and occupation. It is an understatement that these drivers may not lend themselves readily to intervention. To repeat: our concern is with health and health equity. Any political driver that threatens that mission must be identified and analysed. Those with power to change need to recognize the consequences of their actions. Our role is not to become part of the political battle, but to point out the health consequences of political drivers of ill health and inequity.
Economic, commercial and legal policies may represent more amenable intervention points. We will set out how income and the distribution of income affect the conditions of daily life, and thereby influence health equity. We assess fiscal policy in the Region, including tax and public spending and levels of development assistance; examine how commercial interests can damage health or improve it; and identify the steps necessary to make these influences beneficial to health.
Society and culture have the potential to tap into the same sensitivities and deep-seated problems as political drivers. Indeed, they are intertwined throughout the Region. As with political drivers, we see our task as showing how society and culture influence health equity and can be forces for good. This includes harnessing the influence of religious leaders and organizations and making positive contributions to health equity. It is important for health equity to shift gender norms in the Region, which hamper opportunities for women and slow development.
We are living in the Anthropocene – the age of humanity’s profound impact on the planet. Its influences on health include the climate crisis, with attendant extreme heat, droughts, floods and unstable weather, and degradation of the environment. Just as the demands of social justice with respect to health imply building back fairer, so do environmental demands. We need to put the two agendas together for sustainable health equity – building a green economy with benefits for health, the economy and addressing the climate crisis. This will include diversifying energy production, reducing demand for energy and improving water management.
Fig. 1.2. Framework for the social determinants of health in the Eastern Mediterranean Region
Structural drivers
Conflict and consequences
Economic and commercial structures
Culture and society
Natural environment
Conditions of daily life
Maternal and child health, early years and education
Employment and quality of work
Healthy ageing
Built environment
Health systems
Do something, do more, do better: Taking action Governance
Actions Research and monitoring
Health equity and dignified lives
Stratifiers: Position of migrants and refugees, and gender
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We take a life-course approach: addressing the conditions in which people are born, grow, live, work and age. These conditions of daily life are the ways that the structural drivers affect health, but they are not affected equitably. Each of the conditions of daily life show inequitable distributions according to age, socioeconomic position, gender, ethnicity, migrant position and citizenship. It is this inequitable distribution that is responsible for health inequity. The general principle of build back fairer is to structure the conditions of daily life so that all members of society have the conditions that favour leading a life of dignity, thereby creating equity of health and well-being. We outline how to put equity at the heart of government decision-making.
The life-course approach is built on the understanding that equity from the start is essential, beginning with maternal and reproductive health. Not only children’s survival but also the quality of early childhood development is crucial. Nutrition, good cognitive, linguistic, social and emotional development, and protection against adverse childhood experiences are all important in affecting what happens to children throughout their subsequent lives. Early childhood experiences and good-quality education will be powerful influences as the individual enters the world of work, which in turn is an important determinant of health. Important as is early life, opportunities for intervention at an older age should also be taken: improvement in economic and social conditions at older ages can improve health and well-being.
As evidenced in Chapter 2, and shown throughout the Report, socioeconomic inequities in health are not confined to poor health linked to poverty and reasonable health for everyone else. But there is a social gradient: the lower the socioeconomic position, the poorer the health. The implication of this gradient is that policy should not solely aim towards breaking the link between poverty and health, but aim towards levelling up – seeking to improve the health of everyone in society to the level attained by the most socioeconomically advantaged. To achieve this, we elaborate the principle of proportionate universalism (11). We want universalist policies with effort proportionate to need. One key implication is not to treat the “socially excluded” as a category of people with special needs, but to have policies of inclusion in the mainstream.
Respect for human rights is both a principle and a way of taking action. Respecting economic, social and cultural rights,