Eastern Mediterranean Countries Deserve Better Health: Will the New WHO Regional Director Deliver That?
Inside View 24/08/2023 •
A health worker provides treatment to a malnourished child in Yemen.

For most people, electing the regional director – or chief health officer – for the Eastern Mediterranean Region (EMRO) of the World Health Organization (WHO) will not set the pulse racing.  Is this just another shuffling of chairs around the world’s bureaucratic table? Even among global health nerds, it will trigger just a faint tremor.

Yet the role matters to 22 countries spanning the Arab World from Morocco to the Gulf and extending across West Asia to Pakistan. They come together as the Regional Committee for the Eastern Mediterranean to select a new regional director on 10 October to helm the health aspirations of over 700 million hopeful people.

EMRO is one of six regional offices, the directors of which have almost complete authority for executing WHO’s health policies and programmes under its decentralised constitution.  

EMRO’s regional director election comes at a time of health’s increased geopolitical importance due to unpleasant global competition around the COVID-19 pandemic.  Today’s heavily securitised world has also realised that the might of nations is measured not just by guns. Healthy people make content, creative citizens and, ultimately, stronger nations.

EMRO’s life-and-death lottery

WHO EMRO is made up of 22 countries that differ vastly in income and health expenditure.

How is EMRO doing? Its people live 71.4 years, a little under the global average of 73 years. But this hides grave inequalities from Qatar’s 80 years to Somalia’s 55.4 years. Five other nations don’t make it past 66 years.  It is similar with maternal mortality: 620 Afghan women lose their lives for every 100,000 live births, compared to 223 globally. Kuwait does best with seven mothers’ deaths while seven countries are way off the SDG target of 70 maternal deaths per 100,000 live births by 2030.

Why does the region’s heath lag so far behind?  The main cause is that this is the world’s most conflict-torn corner, with two-thirds of its people directly and indirectly affected. Furthermore,  healthcare is brutally instrumentalised with facilities and workers attacked in Yemen, Syria, Iraq, Afghanistan and Pakistan.  Food has been denied in several conflicts with Sudan and Somalia generating starvation headlines and stratospheric malnutrition rates. 

Furthermore, glaring socio-economic gaps hallmark the region. Some of the world’s richest countries – Qatar, the United Arab Emirates (UAE), Saudi Arabia, Bahrain, Kuwait and Oman – are in the same administrative group as Pakistan, Palestine and Egypt, which barely get into the middle-income category, while others like Afghanistan and Yemen remain mired in abysmal poverty.   

This life-and-death lottery is detailed in WHO’s own health observatory, EMRO expends $669 per capita on health – half of the average global spending.  That is skewed further by profligate nations spending $1500-2500, masking other countries that spend less than $150 per person. 

Thousands of Somalis escaping drought and conflict are living in sprawling settlements on the outskirts of towns, like this one in Baidoa in south-central Somalia.

The new regional director needs courage

In such a diverse and divided region, the new regional director will have their work cut out. For starters, they must go courageously where others fear to tread and defend humanity by speaking out without fear or favour. But they must also be astute in walking the fine line between promoting health as a bridge for peace and over-politicising health’s humanitarian mission.

It is our human tendency to get de-sensitised to long-standing suffering and inequalities. Therefore, the incoming regional director will have to be super-human. They must feel stronger outrage about unfairness and injustice, possess greater compassion for misery, burn more intensely with urgency,  be smarter at delving into root causes and shine a brighter light on the path ahead.

Of course, these virtues are nowhere to be found in the sober language of the regional director’s job description. But they should be core considerations for EMRO member states. Can they rise above their usual politicking to unite for the collective good, knowing that the massive health risks they face know no boundaries?

They have six impressive candidates with a range of qualifications and experiences to choose from. Iraq has nominated pharmacologist Najim Abbas Jabir Al-Awwadi and Morocco has proposed former health minister Anass Doukkali. Pakistan has suggested health systems expert Abdul Ghaffar and Iran has put forward health policy professor Ali Akbari Sari. Sudan has nominated its goodwill health ambassador Ahmed Farah Shadoul and Saudi Arabia has proposed the sole woman, clinical and public health specialist Hanan Hassan Balkhy.  If elected, she would be EMRO’s first-ever female regional director, other WHO regions having passed that milestone earlier.

 Consolidation or change?

Whoever is elected, it is not too early to consider their desired legacy from a potential  5-10 years in office. Will they be a transformer or consolidator of business-as-usual?

The business-as-usual approach will see the incumbent – however technically proficient and managerially efficient  – see illusionary progress while presiding over strategic decline. To elaborate: even if the WHO/EMRO leadership does little, health indicators will continue to improve in most countries. Because, thanks to external stimuli, especially the private sector, they will get richer, stabilise some conflicts, improve governance here and there, expand key health capacities, and roll out new technologies wherever they prove useful. 

But such gains are threatened by bigger vulnerabilities. Climate change is heating the Mediterranean and the Middle East at twice the global average with devastating environmental and health impacts. Five of the 10 biggest disasters over the past two years were spawned here, including massive floods, droughts and earthquakes. 

In August 2022, massive floods in Pakistan displaced some 33 million people.

Some 127 million people – 37% of the world’s humanitarian caseload – come from this one region due to a combination of disasters, conflicts, and displacement. WHO’s middling performance on humanitarian assistance in this region needs urgent augmentation.

Concurrently, as the region ages, the burden from non-communicable diseases (particularly diabetes, cardiovascular and lung conditions and cancers) increases. Already 70-80% of deaths occur from NCDs. Other conditions such as substance abuse are surging.

Thus,  business-as-usual in EMRO implies regression. We already see this with continuing neglected tropical diseases such as leishmaniasis, and the emergence of new pandemic-potential agents such as MERS, or the re-emergence of old conditions such as tuberculosis and polio.  

Health systems are struggling in the Middle East and West Asia where health professionals are scarce in poor countries and, although sufficient in the rich ones, skewed towards specialised hospitals. Universal health coverage (UHC), the aspiration that all should receive quality healthcare without personal financial hardship, is still a dream when nearly half the population don’t access 16 essential services.

Healthcare demand will always outstrip provision and traditional health system mantras can never catch up. Will WHO EMRO’s new leader be capable of thinking outside the box? It means breaking old moulds and casting new ones – causing discomfort within WHO and member states. Will they have the guts for that?

Look inwards first for resources

Even if the incoming regional director goes down the egg-breaking, omelette-making track to transform healthcare, they can’t do it on their own. They must build partnerships and garner significant additional resources.

This must start internally inside WHO where its over-staffed headquarters operates out of Geneva, the world’s third most expensive city. Fortunately, WHO Director General Dr Tedros is committed to decentralisation, and although he faces resistance to pushing that through, the incoming regional director should hold him to that pledge. Meanwhile, they must do their utmost to radically reshape EMRO’s regional and country offices to make them investment-worthy.

The new regional director should resist holding out the begging bowl to traditional OECD (mostly Western) donors. The pennies received are not worth the self-respect expended. Multilateral development banks should be pushed to do more. But the real resourcing transformation must be within the region. After all, generosity towards the needy and suffering is an integral part of the region’s dominant religion and culture.

Gulf states are already giving more: $ 9.2 billion in official development assistance in 2022 led by Saudi Arabia ($6.2 billion) and UAE  ($1.4 billion). But such aid tends to be volatile and skewed towards emergency relief and the health sector’s share is small. The regional director must be politically skilled at changing that and establishing long-term health investment – and not donor-recipient – relationships.

Is all this too much to ask from the new WHO EMRO regional director?  No – because it is do-able. Anything less is a betrayal of trust and a missed opportunity to better the lives of people who deserve better.

Mukesh Kapila is a physician and public health specialist who has worked in 120 countries, including as a former United Nations (UN) Resident and Humanitarian Coordinator in Sudan and a UN Special Adviser in Afghanistan.

 

Image Credits: WHO Yemen, Mercy Corp/ TNH, Rahul Rajput.

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