Health status and health systems financing in the MENA region: roadmap to universal health coverage

Urban and rural differences in needs, service use and satisfaction among caregivers of autistic children in Morocco

LAY ABSTRACT

It is very important to understand the needs of caregivers to be able to empower caregivers and to develop or improve services around the world. Therefore, research in different regions is needed to understand differences in caregivers needs between countries, but also between areas within countries. This study investigated differences in needs and service use between caregivers of autistic children in Morocco, living in urban and rural areas. A total of 131 Moroccan caregivers of autistic children took part in the study and responded to an interview survey. The results showed both similarities and differences between urban and rural living caregivers' challenges and needs. Autistic children from urban communities were much more likely to receive intervention and attend school than children from rural communities, even though age and verbal skills of the two groups of children were comparable. Caregivers expressed similar needs for improved care and education, but different challenges in caring. Limited autonomy skills in children were more challenging to rural caregivers, while limited social-communicational skills were more challenging to urban caregivers. These differences may inform healthcare policy-makers and program developers. Adaptive interventions are important to respond to regional needs, resources, and practices. In addition, the results showed the importance of addressing challenges as experienced by caregivers such as costs related to care, barriers in access to information, or stigma. Addressing these issues may help reduce both global and within-country differences in autism care.

The development and application of a two-step surveillance process for Healthy China Initiative based on wide coverage interagency data

BACKGROUND

Healthy China is a nationwide health strategy aiming at improving health from diverse dimensions, and strengthening high-quality assessment is essential for its stimulation. However, there is limited evidence in the surveillance of the actual performance of the initiative at regional levels. This study innovatively proposes a two-step surveillance process which comprehensively monitors Healthy China Initiative based on regional realities, thus provides guidance for policymaking.

METHODS

A flexible indicator system was firstly developed basing on Delphi survey and focus group discussions. And then the Analysis Hierarchical Process and the TOPSIS method were used to determine the weights of indicators and calculate comprehensive indexes as the surveillance outcomes. A pilot study was conducted in a typical area in China to verify the applicability of the process.

RESULTS

Following the surveillance process and basing on the implementation of Healthy China Initiative in the target region, an indicator system comprised of 5 domains and 23 indicators with weights was first developed specifically for the pilot area. Then 1848 interagency data of the study area were collected from 8 provincial institutions/departments to calculate the indexes and ranks of the five domains which were health level, healthy living, disease prevention and control, health service, and healthy environment. The outcomes showed that Healthy China Initiative in the pilot area had been constantly improved since the strategy proposed, while there were still issues to be tackled such as the deficient monitoring mechanisms and unevenly development progress.

CONCLUSIONS

This study proposed a pragmatic surveillance process with indicators which could be tailored for specific context of target regions and produce meaningful surveillance outcomes to inform decision-making for policymakers, and also provided a theoretical foundation as well as empirical evidence for further health strategies and plannings assessment studies.

Healthcare system development in the Middle East and North Africa region: Challenges, endeavors and prospective opportunities

Background

Countries in the Middle East and North Africa (MENA) region have been investing in the development of their health systems through implementing reforms to improve health care delivery for their nations. However, these countries are still facing challenges in providing equitable, high quality healthcare services. There is limited published literature supporting the previous and ongoing attempts that have been made to improve health system performance in MENA countries.

Aims

This review aims to describe experiences of health system development efforts in the MENA region, highlight progress, identify challenges that need be addressed and future opportunities to achieve responsive and efficient health systems. It also aimed to provide recommendations to further support these health systems toward evolution and performance improvement.

Methods

A literature review was conducted by searching different databases including PubMed, Scopus, Google Scholar and other electronic resources to identify articles and publications describing health systems development in the MENA region from 1975 to 2022. It also included grey literature, reports and policy and planning documents by international organizations. The identified references were reviewed to extract, analyze, organize and report the findings.

Results

The review revealed emerging evidence describing governmental initiatives to introduce health system reforms at different levels in the MENA countries. These include initiatives targeting the various elements controlling health system reform: financing, payment, organization, regulation and behavior of providers and consumers. There are several challenges facing the health systems of MENA countries including the rising burden of chronic diseases, inequitable access to health services, deficiency in health workforce, shortage in the use of effective health information systems and leadership challenges. The review identified several key areas that can benefit from further improvement to support health system reforms. These include improving the structure, organization and financing of health systems, health workforce development, effective data management and engagement of key stakeholders to achieve adequate health system reforms.

Conclusion

The MENA countries have made significant steps to improve the performance of their health systems; yet achieving a comprehensive health reform will require collaboration of various stakeholders including health policy makers, healthcare professionals, and central to the success of the reform, the patients.

Cancer registration in the Middle East, North Africa, and Turkey (MENAT) region: A tale of conflict, challenges, and opportunities

Cancer registration is a core component of national and regional cancer control strategies. In the Middle East, North-Africa and Turkey (MENAT) region, capacity and resources for cancer registration is variable and shaped by multiple contextual challenges. This viewpoint maps out practical recommendations around cancer registration, in an attempt to inform cancer control planning, policy, and implementation. The recommendations laid out in this viewpoint are informed by the discussions held at the Initiative for Cancer Registration in the MENAT (ICRIM) virtual workshop, which convened registry managers, policy makers, and international agencies from 19 countries in the MENAT region. The discussions were distilled in four categories of recommendations, revolving around cancer registration procedures, collaborative governance, putting cancer registration on the map, and capacity building. This viewpoint provides a much-needed mapping of practical recommendations around cancer registration, informed by direct key stakeholders in the region. These practical recommendations offer a road map for policy making, cancer control planning, and future regional capacity strengthening initiatives.

Promise of Real-World Evidence for Patient Centricity in Gulf Cooperation Council Countries: Call to Action

Presently, Gulf Cooperation Council countries are lagging in the generation of real-world data and use of real-world evidence for patient-centered care compared with the global average. In a collaborative effort, experts from multiple domains of the healthcare environment from the Gulf Cooperation Council countries came together to present their views and recommended key action points for the generation of robust real-world data and leveraging real-world evidence in the countries. The opinions of the experts are presented, along with existing barriers to the effective generation of real-world evidence in the countries. The Gulf Cooperation Council countries are undergoing transformative changes paving the way for improved healthcare measures; however, the challenges in generating reliable, robust, accessible, and secure real-world evidence are persistent. Hence, ongoing public-private engagements, as well as collaborations between regulators, policymakers, healthcare professionals, insurance and pharmaceutical companies, and patients, are warranted. A few notable examples of real-world evidence studies highlighting the benefits of real-world evidence for gaining valuable insights into patient-centric decision making are also discussed. The actionable steps identified for successful real-world evidence generation would provide long-term, real-world evidence-based patient-centric benefits for the countries.

The burden of chronic respiratory disease and attributable risk factors in North Africa and Middle East: findings from global burden of disease study (GBD) 2019

BACKGROUND

North Africa and Middle East (NAME) has an increasing burden of chronic respiratory diseases (CRDs); however, a systematic understanding of the distribution and trends is not available. We aimed to report the trends of CRDs and attributable risk factors in this region between 1990 and 2019.

METHODS

Using data from the Global Burden of Diseases Study (GBD) 2019, cause specific mortality served as the basis for estimating incidence and disability-adjusted life years (DALYs). The burden attributable to risk factors was calculated by a comparative risk assessment and contribution of population ageing and growth was determined by decomposition analysis.

RESULTS

The number of deaths due to CRD in 2019 were 128,513 (110,781 to 114,351). In 2019, the age-standardized incidence rate (ASIR) of CRDs was 1052.8 (924.3 to 1209.4) per 100,000 population and had a 10.3% increase and the age-standardized death rate (ASDR) was 36.1 (30.9 to 40.3) with a 32.9% decrease compared to 1990. In 2019, United Arab Emirates had the highest ASIR (1412.7 [1237.3 to 1622.2]) and Afghanistan had the highest ASDR (67.8 [52.0 to 81.3]). CRDs were responsible for 2.91% of total DALYs in 2019 (1.69% due to chronic obstructive pulmonary disease [COPD] and 1.02% due to asthma). With regard to the components of DALYs, the age-standardized rate of years of life lost (YLL) had a - 39.0% (- 47.1 to - 30.3) decrease; while the age-standardized rate of years lived with disability (YLD) had a 13.4% (9.5 to 17.7) increase. Of total ASDRs of CRDs, 31.6% were attributable to smoking and 14.4% to ambient particulate matter pollution.

CONCLUSION

CRDs remain a leading cause of death and disability in NAME, with growth in absolute numbers. COPD and asthma were the most common CRDs and smoking was the leading risk factor especially in men. More attention is needed in order to reduce CRDs' burden through appropriate interventions and policies.

The association between health expenditure, institutions, and economic growth in MENA countries

Background: Expenditure on health is vital in the development of a country. Furthermore, the current COVID-19 pandemic emphasises the importance of health investments in maintaining a healthier economy worldwide. A substantial amount of empirical research on the relationship between health expenditure and economic growth yields conflicting results. The study intends to investigate the relationship between health spending and economic growth and institutions’ role in causing health spending to promote growth.

Methods: The study uses longitudinal data to examine the relationship between health spending and economic growth in seven MENA countries from 2000 to 2017. The study uses the Phillips Perron (PP) Fisher chi-square stationarity test, indicating that the data series is not stationary. Following this, we used the Pedroni test for cointegration, and the results show long-run relationships between the variables. Next, Granger causality determines the direction of causality. Finally, panel data methods of panel ordinary least squares (Panel OLS), fully modified OLS (FMOLS), and dynamic OLS (DLOS) supplement the findings.

Results: The Pedroni cointegration test (P value<0.0001) indicates that the variables have a long-run cointegrating relationship. On the other hand, the Granger causality test finds no causal relationships between health spending and economic growth. Furthermore, the panel data models show that expenditure on health does not directly contribute to higher economic growth in MENA countries.

Conclusion: The findings of this study indicate that health spending does not lead to increased economic growth; this could be due to poor institutional quality. However, for health spending to positively impact economic growth, these investments in health care must be supplemented by other factors, particularly institutions.

Socioeconomic disparities in healthcare utilization under universal health coverage: evidence from Dubai household health survey

Background

In 2013, Dubai implemented the Insurance System of Advancing Health in Dubai (ISAHD) law which required mandatory health insurance for all residents of Dubai effective in 2016. This study compares the effect of the ISAHD on the utilization and out-of-pocket (OOP) expenditures for low and high socio-economic status sub-groups.

Methods

The study used the 2014 and 2018 Dubai Household Health Survey (DHHS) a representative survey of Dubai stratified as: 1) Nationals; 2) Non-nationals in households; 3) Non-nationals in collective housing; and 4) Non-nationals in labor camps. The probability that each household would have expenditures was calculated, then multiplied by a weighted estimate of the average total OOP expenditure.

Results

Overall Dubai’s health spending rose from 12.8 billion AED (3.4 billion US $) in 2014 to 16.8 billion AED (4.6 billion US $) in 2017. Concurrently, the OOP share in total health spending in Dubai fell from 25% in 2014 to 13% in 2017. From 2014 to 2018, there were increases in the utilization of inpatient, outpatient and discretionary services for all groups except non-nationals living in camps. In 2018, nationals spent a total of 1064.65 AED, non-nationals in households spent 675.01 AED, collective households spent 82.35 AED, and labor camps spent 100.32 AED out-of-pocket per capita for healthcare expenditures. During and after the implementation of ISAHD, there was a substantial growth in the OOP expenditure per capita for nationals and non-nationals in households due to increased utilization. OOP spending did not rise for the lower-income non-National households.

Conclusion

Dubai has been successful in reducing the household share of OOP expenditures by shifting the financial burden to government and employers. Emiratis and expatriate households increased their health service utilization after ISAHD but blue-collar workers did not. Remaining non-financial barriers to care for Dubai’s blue-collar workers must be identified and addressed.

Assessment of the Educational and Health Care System-Related Issues From Physicians' and Nurses' Perspectives Before Developing a Palliative Care Program Within the Palestinian Health Care System: A Cross-sectional Study

A scarcity in research assessing the palliative care (PC) educational and health care system-related issues has been reported in the Middle East region; the region comprises a wide range of economically diverse countries. Discrepancies across countries have created difficulties in adopting other countries' experiences. This study aimed to assess PC knowledge, attitude, educational needs, and health care system-related issues from physicians' and nurses' perspectives before developing PC services within the Palestinian health care system. One hundred sixty-nine professionals participated in this cross-sectional survey. Data were collected by validated instruments. Professionals had insufficient knowledge about PC, but they had positive attitudes toward end-of-life care and care of the dying. Patients'/families' avoidance of talking about issues around dying and lack of training for staff related to PC were the most 2 significant barriers to providing PC. Educational level and previous training were found to be associated significantly with knowledge and attitudes toward PC. Study conclusions support the recommendation for integration of education about PC within the health curricula and in-service training and should cover the basic and advanced principles of PC and symptom management.

A Systematic Review on Economic Evaluation Studies of Diagnostic and Therapeutic Interventions in the Middle East and North Africa

INTRODUCTION

Due to the increase in healthcare budget constraint, economic evaluation (EE) evidence is increasingly required to inform resource allocation decisions. This study aimed to systematically review quantity, characteristics, and quality of full EE studies on diagnostic and therapeutic interventions conducted in 26 Middle East and North Africa (MENA) countries.

METHODS

PubMed and Scopus databases were comprehensively searched to identify the published EE studies in the MENA region. The quality of reviewed studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The search identified 69 studies. The cost-utility approach was adopted in 49 studies (71 %). More than half (38 studies; 55 %) were conducted in Iran and Turkey. Sixteen countries (62 %) did not have any EE studies. The most frequently analyzed therapeutic areas were infectious diseases (19 studies; 28 %), cardiovascular diseases (11 studies; 16 %), and malignancies (10 studies; 14 %). Ten studies (14 %), 46 (67 %), 12 (17 %), and 1 study (1 %) were classified as excellent, high, moderate, and poor quality, respectively. The mean of items reported was 85.10 % (standard deviation 13.32 %). Characterizing heterogeneity, measurement of effectiveness, time horizon, and discount rate were missed in 21 (60 %), 22 (32 %), 20 (29 %) and 15 (25 %) studies, respectively. Data on effectiveness and utility relied primarily on studies conducted outside the region.

CONCLUSIONS

The quantity of EE studies in the MENA region remains low; however, overall quality is high to excellent. The availability of local data, capacity building, and national guidelines are vital to improve both the quantity and quality of EE studies in the region.

A systematic review of economic evaluations of vaccines in Middle East and North Africa countries: is existing evidence good enough to support policy decision-making?

INTRODUCTION

A vaccine introduction process should be systematic and transparent and take into account many factors, including cost-effectiveness evidence. This study aimed to assess quantity, characteristic, and quality of economic evaluation (EE) studies on vaccines performed in Middle East and North Africa (MENA) countries.

AREAS COVERED

PubMed and Scopus electronic databases were searched since inception to December 2019 to identify published EE studies of vaccines, which were conducted in the 26 MENA countries. Methodological quality of the included studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

EXPERT OPINION

Of the 616 studies identified, 46 were included in the review. Most studies (65%) were conducted in Iran, Israel, and Turkey. The most commonly evaluated vaccines were rotavirus vaccine (n = 15; 33%), human Papillomavirus vaccine (n = 8; 17%), and pneumococcal vaccine (n = 7; 15%). We classified 5 (11%), 27 (59%), 12 (26%), and 2 (4%) studies as excellent, good, moderate, and poor quality, respectively. There were limited cost-effectiveness evidences in the region. It is imperative to have local guidelines on good practice and reporting, availability of local data, and funding sources to improve quantity and quality of EE studies of vaccines in the region, thereby, facilitating transparent and consistent decision-making processes.

An analysis of policy and funding priorities of global actors regarding noncommunicable disease in low- and middle-income countries

BACKGROUND

Noncommunicable diseases (NCDs), including mental health, have become a major concern in low- and middle-income countries. Despite increased attention to them over the past decade, progress toward addressing NCDs has been slow. A lack of bold policy commitments has been suggested as one of the contributors to limited progress in NCD prevention and management. However, the policies of key global actors (bilateral, multilateral, and not-for-profit organisations) have been understudied.

METHODS

This study aimed to map the key global actors investing in action regarding NCDs and review their policies to examine the articulation of priorities regarding NCDs. Narrative synthesis of 70 documents and 31 policy papers was completed, and related to data collated from the Global Health Data Visualisation Tool.

RESULTS

In 2019 41% of development assistance for health committed to NCDs came from private philanthropies, while that for other global health priorities from this source was just 20%. Through a range of channels, bilateral donors were the other major source of NCD funding (contributing 41% of NCD funding). The UK and the US were the largest bilateral investors in NCDs, each contributing 8%. However, NCDs are still under-prioritised within bilateral portfolios - receiving just 0.48% of US funding and 1.66% of the UK. NGOs were the key channels of funding for NCDs, spending 48% of the funds from donors in 2019. The reviewed literature generally focused on NCD policies of WHO, with policies of multilateral and bilateral donors given limited attention. The analysis of policies indicated a limited prioritisation of NCDs in policy documents. NCDs are framed in the policies as a barrier to economic growth, poverty reduction, and health system sustainability. Bilateral donors prioritise prevention, while multilateral actors offer policy options for NCD prevention and care. Even where stated as a priority, however, funding allocations are not aligned.

CONCLUSION

The growing threat of NCDs and their drivers are increasingly recognised. However, global actors' policy priorities and funding allocations need to align better to address these NCD threats. Given the level of their investment and engagement, more research is needed into the role of private philanthropies and NGOs in this area.

Determinants of dental caries in children in the Middle East and North Africa region: a systematic review based on literature published from 2000 to 2019

Background

Dental caries risk factors have been expanded to not only emphasize biology, dietary and oral habits but also broader social determinants such as socioeconomic factors and the utilization of health services. The aim was to review sociobehavioural/cultural and socioeconomic determinants of dental caries in children residing in the Middle East and North Africa (MENA) region.

Methods

A search was conducted in the PubMed/Medline database and Google Scholar to identify studies published from 2000 to 2019 covering children using key search terms. In the initial stages, titles, abstracts and, if needed, full articles were screened for eligibility. In the final stage, all included articles were reassessed and read, and relevant data were extracted.

Results

Out of 600 initial articles, a total of 77 were included in this review, of which 74 were cross-sectional, 2 were longitudinal and one was a case–control study. The studies included a total of 94,491 participants in 14 countries across the MENA region. A majority used the World Health Organization scoring system to assess dental caries. The caries prevalence ranged between 17.2% and 88.8%, early childhood caries between 3% and 57% and decayed missing filled teeth (dmft) varied between 0.6 and 8.5 across the various age groups. Increased age, low maternal education, low overall socioeconomic status, decreased frequency of tooth brushing, low parental involvement, poor oral habits, infant feeding practices and sugar consumption were among the most prevalent determinants for increased risk of caries in the reviewed studies.

Conclusions

Dental caries was found to be high among children in many of the studies published from MENA. The key determinants of dental caries were found to include factors related to child characteristics, family background, oral hygiene and infant feeding and eating habits. The high dental caries prevalence emphasises the need to address the prevailing modifiable sociobehavioural and socioeconomic determinants by translating them into effective oral health prevention policies and programmes.

Social and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study

Background

The aim of this study was to explore and measure the social and economic consequences of the costs of obstetric and neonatal care in Lubumbashi, the Democratic Republic of Congo.

Methods

We conducted a mixed qualitative and quantitative study in the maternity departments of health facilities in Lubumbashi. The qualitative results were based on a case study conducted in 2018 that included 14 respondents (8 mothers of newborns, 2 accompanying family members and 4 health care providers). A quantitative cross-sectional analytical study was carried out in 2019 with 411 women who gave birth at 10 referral hospitals. Data were collected for one month at each hospital, and selected mothers of newborns were included in the study only if they paid out-of-pocket and at the point of care for costs related to obstetric and neonatal care.

Results

Costs for obstetric and neonatal care averaged US $77, US $207 and US $338 for simple, complicated vaginal and caesarean deliveries, respectively. These health expenditures were greater than or equal to 40% of the ability to pay for 58.4% of households. At the time of delivery, 14.1% of women giving birth did not have enough money to pay for care. Of those who did, 76.5% spent their savings. When households did not pay for care, mothers and their babies were held for a long time at the place of care. This resulted in the prolonged absence of the mother from the household, reduced household income, family conflicts, and the abandonment of the home by the spouse. At the health facility level, the increase in length of stay did not generate any additional financial benefits. Mothers no longer had confidence in nurses; they were sometimes separated from their babies, and they could not access certain prescribed medications or treatments.

Conclusion

The government of the DRC should implement a mechanism for subsidizing care and associate it with a cost-sharing system. This would place the country on the path to achieving universal health coverage in improving the physical, mental and social health of mothers, their babies and their households.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03765-x.

Prevalence of Common Gynecological Conditions in the Middle East: Systematic Review and Meta-Analysis

Introduction: High prevalence of gynecological conditions in women of Middle Eastern origin is reported, likely due to regional risk factors and mediators. The objective of this systematic review and meta-analysis is to investigate the prevalence of polycystic ovary syndrome (PCOS), endometriosis, uterine fibroids, and adenomyosis in women of Middle Eastern origin. Methods: MEDLINE, EMBASE, PsycINFO, Global Health, and Google Scholar databases were searched from database inception until 14 February 2021 to identify relevant studies. Peer-reviewed research articles that reported the prevalence of PCOS, endometriosis, uterine fibroids, and adenomyosis in the Middle Eastern population were written in English or Arabic. The primary outcome was the estimated pooled prevalence of PCOS, endometriosis, uterine fibroids, and adenomyosis in the Middle Eastern populations. The secondary outcome was to assess the evidence in the data for the presence of heterogeneity, by conducting subtype-pooled analysis of prevalence estimates of the conditions. Total weighted prevalence was calculated via Freeman-Tukey arcsine transformation and heterogeneity through the I 2 statistic. Quality control was performed using GRADE criteria. Results: A total of 47 studies, 26 on PCOS, 12 on endometriosis, eight on uterine fibroids, and seven on adenomyosis, were included. The pooled prevalence of PCOS diagnosed according to the NIH criteria was 8.9% (95% CI: 6.5-11.7; prevalence range: 4.0-27.6%), with a higher prevalence from the Gulf Arab states (18.8%, 95% CI: 9.5-30.3; range: 12.1-27.6%). According to the Rotterdam criteria, the pooled prevalence of PCOS was 11.9% (95% CI: 7.1-17.7; range: 3.4-19.9%) with studies limited to the Persian and Levant regions. Endometriosis was diagnosed in 12.9% (95% CI: 4.2-25.4; range: 4.2-21.0%) of women undergoing laparoscopy, for any indication. Uterine fibroid and adenomyosis prevalence of women was 30.6% (95% CI: 24.9-36.7; range: 18.5-42.6%) and 30.8% (95% CI: 27.1-34.6, range: 25.6-37.7%), respectively. Heterogeneity was present between studies due to statistical and methodological inconsistencies between studies, and quality of evidence was low due to sample size and unrepresentative participant selection. Conclusion: This is the first review that has reported the prevalence of gynecological diseases in the Middle Eastern population, suggesting that gynecological morbidity is a public health concern. Due to the health disparities in women, further research is required to understand the relative roles of environmental and genetic factors in the region to serve as a benchmark for evaluation and comparative purposes with other populations.

Rabies in the Middle East, Eastern Europe, Central Asia and North Africa: Building evidence and delivering a regional approach to rabies elimination

The Middle East, Eastern Europe, Central Asia and North Africa Rabies Control Network (MERACON), is built upon the achievements of the Middle East and Eastern Europe Rabies Expert Bureau (MEEREB). MERACON aims to foster collaboration among Member States (MS) and develop shared regional objectives, building momentum towards dog-mediated rabies control and elimination. Here we assess the epidemiology of rabies and preparedness in twelve participating MS, using case and rabies capacity data for 2017, and compare our findings with previous published reports and a predictive burden model. Across MS, the number of reported cases of dog rabies per 100,000 dog population and the number of reported human deaths per 100,000 population as a result of dog-mediated rabies appeared weakly associated. Compared to 2014 there has been a decrease in the number of reported human cases in five of the twelve MS, three MS reported an increase, two MS continued to report zero cases, and the remaining two MS were not listed in the 2014 study and therefore no comparison could be drawn. Vaccination coverage in dogs has increased since 2014 in half (4/8) of the MS where data are available. Most importantly, it is evident that there is a need for improved data collection, sharing and reporting at both the national and international levels. With the formation of the MERACON network, MS will be able to align with international best practices, while also fostering international support with other MS and international organisations.

Impact of Healthcare Expenditures on Healthcare Outcomes in the Middle East and North Africa (MENA) Region: A Cross-Country Comparison, 1995-2015

The association between healthcare expenditures and outcomes, mainly mortality and life expectancy, is complex. The real explanation for this association is not clear, especially in the Middle East and North Africa (MENA) region. This study assesses the impact of health expenditures on improving healthcare systems and health status and finds a relationship between health expenditures and health outcomes across different region. Annual time series data on healthcare spending and outcomes from 1995 to 2015 were used for MENA region in comparison to developed and developing countries. Health expenditure was adjusted by the consumer price index equation to the 2015 US dollar eliminate the impact of inflation on our results. For many countries, spending on healthcare continues to rise, Among MENA countries, we found that the United Arab Emirates and Kuwait spent more per capita on health, $1,711 and $1,420, respectively, than any other countries in the region. Although this study demonstrated a relationship between total healthcare expenditure and outcomes, some countries spend more on healthcare but have shorter life expectancy. In most countries, efficient and effective utilization of healthcare resources is the key strategy for improving health outcomes in any country. The lack of a positive correlation between healthcare spending and life expectancy may indicate that health resources are not allocated effectively. In those cases, increasing health spending does not guarantee that there is any kind of improvement in healthcare.

Depressed, anxious, and stressed: What have healthcare workers on the frontlines in Egypt and Saudi Arabia experienced during the COVID-19 pandemic?

INTRODUCTION

As the Novel Corona Virus Disease (COVID-19) was declared by the world health organization a pandemic in March 2020, thousands of healthcare workers (HCWs) worldwide were on the frontlines fighting against the pandemic. Herein, we selected two Middle East countries; Egypt and Saudi Arabia to investigate the psychological impacts of the COVID-19 pandemic on their HCWs.

METHODS

In this cross-sectional study, a Google survey was used to access HCWs in many hospitals in Egypt and Saudi Arabia between the 14th and 24th of April 2020. The survey assessed HCWs regarding their sociodemographic and occupational features, sleeping hours, and psychological impacts of the COVID-19 pandemic using the Depression Anxiety Stress Scale-21 (DASS-21).

RESULTS

This study included 426 HCWs (48.4% physicians, 24.2% nurses, and 27.4% other HCWs). Of them, 69% had depression, 58.9% had anxiety, 55.9% had stress, and 37.3% had inadequate sleeping (<6 h/day). Female sex, age ≤30 years, working in Egypt, attending emergency and night shifts, watching/reading COVID-19 news ≥2 h/day, and not getting emotional support from family, society, and hospital were associated with a high likelihood of depression, anxiety, stress, and inadequate sleeping.

LIMITATIONS

the cross-sectional design restricted our ability to distinguish between preexisting and emerging psychological symptoms.

CONCLUSION

HCWs on the frontlines in Egypt and Saudi Arabia experienced depression, anxiety, stress, and inadequate sleeping during the COVID-19 pandemic.

Psychological Impacts of the COVID-19 Pandemic on the Public in Egypt

This study aimed to evaluate the prevalence of depression, anxiety, stress, and inadequate sleeping among the public in Egypt during the novel Corona Virus Disease (COVID-19) pandemic. An online snowball sampling approach was used to collect data from netizens in four Egyptian governorates between 16 and 30 April 2020. A semi-structured questionnaire was designed to assess sociodemographic characteristics, sleeping hours per day, and psychological disturbances (depression, anxiety, and stress) of participants using the Depression Anxiety Stress Scale-21. Out of 1629 participants, 48.1% were aged ≤ 30 years, 42.4% were men, and 20.0% were working in the health sector. The participants reported a high prevalence of depression (67.1%: mild to moderate 44.6% and severe to very severe 22.5%), anxiety (53.5%: mild to moderate 30.6% and severe to very severe 22.9%), stress (48.8%: mild to moderate 33.8% and severe to very severe 15.0%), and inadequate sleeping (< 6 h/day) 23.1%. Female sex, working in sectors other than the health sector, watching/reading COVID-19 news ≥ 2 h/day, and lack of emotional support from family and society were associated with a high prevalence of severe to very severe depression, anxiety, and stress. In conclusion, the psychological impacts of COVID-19 on the public in Egypt were enormous, therefore, providing psychological support and counsel is warranted.

Place and health infrastructure in the Gulf Cooperation Council: A systematic scoping review of GIS applications in health

The rising burden of non-communicable diseases is taxing health systems globally. Using data science and information systems is necessary to support public health practices. Geographic Information Systems (GIS) are key to inform and help guide public health policies related to place (i.e. location or where one lives) and how it affects health. Despite the increasing use of GIS for public health globally, its applications to health in the Gulf Cooperation Council (GCC) states remains largely unknown. This systematic scoping review aimed to uncover how GIS has been used in the GCC states to understand "place" and "health". A comprehensive search of the literature was performed in PubMed, Scopus, Science Citation Index Expanded, ScienceDirect, Embase, IEEE Xplore, and ACM Digital Library during June 2020. All journal articles involving the use of GIS for human health applications in the GCC states published in English in peerreviewed scientific journals were considered. After removing duplicates and applying eligibility criteria, qualitative content analysis was performed for 24 of 630 studies. GIS uses in the GCC states were categorized as health access and planning (n=9), health risk analysis (n=8), disease surveillance (n=6) and community health profiling (n=1). The majority of the uncovered evidence in this study focused on the Kingdom of Saudi Arabia. The results of this study indicate a deficiency of published evidence regarding the use of GIS in support of public health in other GCC states. This stands to compromise planning and strategic decision making in health risk analysis, disease surveillance, community health profiling, health services provision and health interventions.

Prevalence, Determinants, and Effects of Food Insecurity among Middle Eastern and North African Migrants and Refugees in High-Income Countries: A Systematic Review

Issues related to poverty and income inequality in high-income countries have led to food insecurity among some population groups, such as migrants and refugees. While there are some studies on the experience of some migrant groups (and other subpopulations), little is known about food security among Middle Eastern and African migrants and refugees. This systematic review identified the prevalence of food insecurity and its effects among Middle Eastern and North African (MENA) migrants and refugees in high-income countries. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in this systematic review. Four databases, namely MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and PubMed were searched. Three studies met the inclusion criteria, all of which were conducted in USA: two among Sudanese migrant families, and one among Somali refugee women. The rates of reported food insecurity ranged from 40% to 71% and were significantly higher than for the general population. Food insecurity was associated with acculturation and socio-economic factors. Food insecurity adversely impacts the health of MENA migrants and refugees, creating economic implications for individuals, families, the broader community in which they now live, and for governments.

Health Economic Publications From the Middle East and North Africa Region: A Scoping Review of the Volume and Methods of Research

Introduction

We reviewed the scope of countries, diseases, technologies, and methods involved in the health economic evaluations published in the Middle East and North Africa (MENA) region.

Methods

PRISMA guidelines were followed. A PubMed search was conducted up to December 15, 2019. English language full-text articles were included if they reported original research on humans; involved the local population from Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, or Yemen; reported costs; and involved a full or partial health economic analysis comparing alternative health technologies. Data on publication year, country of origin, disease area according to ICD-10, type of health technology, and applied methods were extracted.

Results

From 105 eligible articles, 57.1% were published between 2015 and 2019. Egypt (30.5%) and Saudi Arabia (27.6%) were the most frequently involved countries. Infectious diseases were most often studied (27.6%). The assessed technology was a system (eg, infection control, screening, coverage/access, hospital management, or healthcare delivery program) in 41.9% of studies. Cost-utility analysis (CUA) was the most frequent method (29.5%) and was growing rapidly. Health system perspective was adopted in 52.4% of studies, whereas societal perspective was scarce (8.6%). The majority of studies (46.7%) were published in Scimago Q1 journals. Over half of the studies (54.2%) did not report or did not have a funding source.

Conclusions

From 2015, health economic analysis became more frequent in the MENA region, providing input to value-based health policy and financing. For further growth, in addition to the development of the institutional background, valid and more standardized local cost and outcome data should be available.

Health Status in the Islamic Republic of Iran, Middle East and North Africa Countries: Implications for Global Health

BACKGROUND

The aim of this study was to evaluate the health status of the Iranians following the sustainable development goals' (SDGs) introduction and the recent health reform implementation in Iran and to compare with those of the Middle East and North Africa region (MENA) and global average.

METHODS

This comparative study used secondary data to investigate socio-demographic and health status indicators. The sources included census, population-based surveys and death registries. Global and regional health status indicators were obtained from international databases including WHO, the World Bank and the Institute for Health Metric and Evaluation (IHME).

RESULTS

Life expectancy and human development index improved following the reform implementation. Among causes of death, 74.6% were attributed to non-communicable diseases (NCDs). There was an increasing trend in risk factors for NCDs in Iran, while at the same time neonatal, infant and under-5 mortality rates reduced. Compared to the MENA, Iran has a lower maternal mortality ratio, neonatal, infant, and under-5 mortality rates, and a higher life expectancy. NCDs and road traffic injuries accounted for a larger portion of disability-adjusted life years in Iran compared to the MENA and worldwide.

CONCLUSION

Actions against communicable diseases and road traffic injuries are required together with continued efforts to address NCDs. Although based on the results, Iran has relatively high rankings, there is a need to develop a roadmap to accelerate achieving global health goals and SDGs targets.

Ophthalmic services during ongoing conflict: the eye health system in Yemen

There is little information on the provision of ophthalmic services and the eye health system in Yemen. Using the WHO framework for analysing health systems, we aim to assess what is known about the current eye health system in Yemen with ongoing conflict. Financial constraints, transportation difficulties and security instability are barriers for many of Yemen’s people in need of healthcare. The most recent cataract surgical rate reported in 2012 is 2473 operations per million population, with an increase in operations performed in charity eye camps and the private sector. We identify many governorates of Yemen have inadequate ophthalmic resources. We describe the need for short-term solutions to reduce the backlog prevalence of blindness while local infrastructure is rebuilt, and the importance of long-term reconstruction and transition to local ownership with a sustainable workforce and health service as peace is restored.

Evaluating hospital websites in Kuwait to improve consumer engagement and access to health information: a cross-sectional analytical study

BACKGROUND

Current advances in information and communication technology have made accessing and obtaining health-related information easier than ever before. Today, many hospital websites use a patient-centric approach to promote engagement and encourage learning for better health-related decision making. However, little is known about the current state of hospital websites in the State of Kuwait. This study aims to evaluate hospital websites in Kuwait and offer recommendations to improve patient engagement and access to health information.

METHODS

This study employs a cross-sectional analytical approach to evaluate hospital websites in Kuwait in 2017. The websites of hospitals that provide in-patient services were identified through a structured search. Only active websites that were available in either English or Arabic were considered. The evaluation of the websites involved a combination of automated and expert- based evaluation methods and was performed across four dimensions: Accessibility, Usability, Presence, and Content.

RESULTS

Nine hospitals met the inclusion criteria. Most of the websites fell short in all four dimensions. None of the websites passed the accessibility guidelines. The usability of websites varied between hospitals. Overall, the majority of hospitals in Kuwait have rudimentary online presence and their websites require careful reassessment with respect to design, content, and user experience. The websites focus primarily on promoting services provided by the hospital rather than engaging and communicating with patients or providing evidence-based information.

CONCLUSIONS

Healthcare organization and website developers should follow best-practices to improve their websites taking into consideration the quality, readability, objectivity, coverage and currency of the information as well as the design of their websites. Hospitals should leverage social media to gain outreach and better engagement with consumers. The websites should be offered in additional languages commonly spoken by people living in Kuwait. Efforts should be made to ensure that health information on hospital websites are evidence-based and checked by healthcare professionals.

Productivity change of national health systems in the WHO Eastern Mediterranean region: application of DEA-based Malmquist productivity index

BACKGROUND

The pursuit of efficiency and productivity is one of the goals of health systems. In the era of Sustainable Development Goals and particularly the move towards universal health coverage, it is imperative to curb wastage of resources to ensure sustainable access of the population to needed and effective health services without enduring financial hardship. This study aims to assess total factor productivity change of national health systems of 20 countries in the WHO's Eastern Mediterranean Region.

METHODS

Data Envelopment Analysis (DEA)-based Malmquist index is used to assess total factor productivity change and its components - efficiency change and technical change. To assess the robustness of the Malmquist index estimates, bootstrapping was performed. Outputs used are life expectancy at birth for both sexes and infant mortality; while total expenditure on health per capita in international dollars (PPP) is used as a measure of input. Panel data for the period 2003-2014 was extracted from databases of the WHO and the World Bank.

RESULTS

In all but five countries covered in the study, a decline in the mean total factor productivity is observed during the period 2003-2014. The decline is driven by technical regress. In all countries, the technical change component of the Malmquist TFP index is less than unity (range: 0.896 to 0.945). All countries exhibited growth in efficiency (efficiency change exceeding one) except two countries (Djibouti and Iraq). The growth in efficiency was mainly due to change in scale efficiency. Overall, total factor productivity in the region declined by 3.8%. This was due to a 9.1% decline in technical change, which overshadowed the 5.8% increase in efficiency. Three countries - Libya, Qatar and Yemen - showed a marginal growth in total factor productivity. There was no change in total factor productivity in Kuwait and Lebanon.

CONCLUSION

The decline in total factor productivity over the study period is likely to hamper achieving the targets of Sustainable Development Goal 3 of ensuring healthy lives and promoting well-being for all at all ages. It is recommended that country-level studies on efficiency and productivity of health systems be conducted in order to intensively examine the determinants of inefficiency and productivity decline and implement appropriate interventions that could enhance efficiency and productivity.