After the Pandemic: Reimagining the Role of State and Non-State Actors in (Re)building National Health Systems in the Arab World

In the Arab region, countries have become increasingly dependent on non-state actors, notably the private sector, for healthcare provision and any response that includes the State alone may not be sufficient to address the COVID-19 pandemic. This paper explores how state and non-state actors in Arab countries have collaborated so far and suggests ways forward to ensure quality healthcare services for all.

A Kuwaiti health ministry workers check the body temperature of expatriates who travelled abroad between February and March 2020. © EPA/NOUFAL IBRAHIM

*This piece is published in collaboration with Chatham House. It is part of a series which addresses the future of governance and security in the Middle East and North Africa, and their impact on the role of the state in the region.

As new cases of the novel coronavirus (COVID-19) continue to surge, countries around the world struggle to mitigate the public health and economic effects of the virus. The huge influx of patients has stretched the limits of national health systems, with severe shortages in competent healthcare personnel and essential medical supplies (Horowitz, 2020). It is becoming increasingly clear that an effective pandemic response requires a whole-of-government, whole-of-society approach (Kim, 2015; Shwartz and Yen, 2017; WHO, 2020). This calls for a collaborative response that draws on the capacities and resources of multi-sectoral, state and non-state actors, comprised of private, for-profit and not-for-profit organizations including civil society organizations (WHO, 2020). Recent developments worldwide have helped to demonstrate how state and non-state actors have interacted in the face of the coronavirus pandemic. In England, the National Health Service (NHS) has entered into an agreement with the private sector to reallocate private hospital capacity to the NHS (Tiggle, 2020). In Ireland and Spain, the state has made all private hospitals public for the duration of the coronavirus crisis (Payne, 2020; Ryan, 2020).

In the Arab world, a whole-of-society response to the coronavirus pandemic is particularly critical, as countries have become increasingly dependent on non-state actors, notably the private sector, for healthcare provision and any response that includes the State alone may not be sufficient to address the pandemic (ESCWA, 2013; Shepp, 2020; WHO, 2020). Additionally, there is growing recognition that new models of collaboration between state and non-state actors are needed to accelerate progress towards Universal Health Coverage (UHC). However, there are questions on how state and non-state actors in Arab countries can collaborate to provide quality healthcare services for all. The unfolding of the pandemic revealed common patterns across Arab countries that can help draw insights for the future role of state and non-state actors.

Role of non-state actors in responding to the coronavirus pandemic in the Arab world

Countries from the Arab world engaged with the private sector to varying degrees and in different ways in the fight against COVID-19. For example, in the United Arab Emirates, a private network of healthcare providers made staff and hospital bed capacity available when needed by government authorities (Khaleej Times, 2020). In Bahrain, the State provided licenses to private healthcare providers that meet the World Health Organization’s standards for the management of COVID-19 in order to provide services to patients who prefer to pay for care in the private sector (Bahrain MOH, 2020). Non-governmental organizations in Iraq expressed their readiness to support the government through the distribution of hygiene kits, training of health workers and protection monitoring, and provision of cash to affected families (NCCI, 2020).

At the same time, the coronavirus pandemic demonstrated that systematic and comprehensive engagement with non-state actors seems to be absent from the national response of countries. Effective prevention and control of COVID-19 requires a highly coordinated response across state and non-state actors in providing a wide scope of services, including prevention and control of COVID-19 and maintaining essential services (WHO, 2020).

Even in countries where the government issued policies to engage with non-state actors, there was ambiguity and inconsistency in implementation. This can be seen in Lebanon, where despite the predominance of the private sector in service provision and a ministerial decree to engage the private sector in the fight against the spread of coronavirus, there is no clear plan for coordination between the government and non-state actors (El- Jardali et al., 2020). Poor involvement of private hospitals in Lebanon can likely be attributed to high treatment costs, the need for safety and infection control measures, and delayed third party payers’ remuneration (El- Jardali et al., 2020).

Furthermore, country efforts are mainly focused on engaging private hospitals and laboratories to fill gaps in states’ healthcare provision and coverage (Tayih, 2020), despite the important role that other actors such as primary healthcare centres, nursing home facilities, and civil society can play in extending critical services, such as educating and empowering communities against viral spread and providing social support and care to vulnerable populations (Clarke and Paviza, 2018).

Re-imagining the role of the State in the Arab world post coronavirus pandemic

The coronavirus pandemic has exposed the fragility of health systems worldwide. In the Arab world, where health systems are already strained by armed conflicts and displaced populations, the pandemic is expected to further exacerbate fragilities and deepen vulnerabilities (Abdellatif and Hsu, 2020). While the pandemic will have grave health and economic consequences for years to come, it brings with it a valuable opportunity to re-envision the role of state and non-state actors in strengthening health systems.

The State as a coordinator and regulator of health systems

Governments from Arab countries should assume leadership in coordinating roles and responsibilities in healthcare services provision across state and non-state actors (Clarke et al., 2019; Kim, 2015). They should harness non-state actors to help meet national priorities, including the role of the private sector in UHC, and ensure that all actors are aligned with these priorities (Clarke et al., 2019). Strong coordination is needed to ensure that all sectors are working collaboratively to achieve a whole-of-government, whole-of-society response for addressing pressing national challenges and building resilient health systems.

Essential to fostering collaboration between state and non-state actors is data sharing and transparency (Shwartz and Yen, 2017). This pandemic has demonstrated that real-time information sharing is integral to effective response. Yet, lack of data sharing and transparent reporting continued to weaken health systems in the region, even in this time of crisis. This highlights the need for governments to strengthen regulation, foster accountability, and build mutual trust (Kim, 2015; WHO 2020). In recent years, we have seen governments in the region assume a stronger role in regulation. For example, in Bahrain, the State’s role has been shifting away from health services delivery to that of planning and regulation (ESCWA, 2013), and in Lebanon the Ministry of Public Health has applied several reforms including performance-based contracting (Khalife et al., 2017). However, governments need to step up these efforts. Innovative context-specific regulatory mechanisms are needed to ensure that services provided by non-state actors meet standards and are efficient and equitable (Kim, 2015; Clarke et al., 2019; WHO, 2020).

Towards evidence-informed public health policymaking

The coronavirus outbreak demonstrated that there is severe shortage in public health expertise in the region. Even in countries where expertise was available, governments did not leverage this expertise to face of the crisis. Instead, political and economic considerations have prevailed over health directives. For example, in Egypt and Lebanon political factors most likely have contributed to the delay in the government’s decision to respond promptly to the threats of the coronavirus pandemic (Arab Center Washington DC, 2020).

In crises of such devasting scale and intensity, using the best available evidence could make the difference between life and death. A key question remains: How can public health expertise be integrated within the State’s policymaking processes to ensure that governments prepare and respond to a crisis using the best available evidence on what works? Various organizational arrangements can influence the level of integration and institutionalization between experts and policymakers. These include committees within ministries, knowledge translation platforms, publicly funded-external organizations, and independent non-governmental organizations (Koon et al., 2018). However, further research is needed on effective arrangements for institutionalizing evidence within the unique public health policymaking context of Arab countries (Koon et al., 2018; Koon et al., 2020).

Multi-sectoral action for driving innovation and technology

It is now more apparent than ever that new technologies such as the use of big data and artificial intelligence are essential for delivering an effective public health response, particularly for case identification and containment of the pandemic (Wang et al., 2020; El-Jardali et al., 2020). For example, in Taiwan, people in quarantine were tracked using location sharing on their mobile phone (Wang et al., 2020). Globally, chatbot helpers were used to update the population about the virus and help healthcare providers assess COVID-19 risk in patients (HIMSS Media, 2020).

Significant variations exist in the availability and access to technological tools and connectivity across Arab countries and between the private and public sectors, with low- and middle-income countries and public sectors at a disadvantage (ESCWA, 2013; Arab Center Washington DC, 2020). The COVID-19 pandemic has deepened this digital divide, whereby populations with lower accessibility and quality of access are less likely to have access to information and prevention guidelines and are prone to health risks (Arab Center Washington DC, 2020). Accelerating the use of novel technology, such as leveraging on artificial intelligence, machine learning, big data and digital tools, to achieve better public health outcomes and ensuring equal access to technology are priority areas for the State to lead multi-sectoral collaboration in all types of organizations and sectors.

Towards recognizing health as a basic human right

It took a pandemic for countries to realize that we live in one world and that social inequalities and equity issues will hurt us all equally. The coronavirus pandemic has exposed severe inequalities and inequities in health systems worldwide. In the Arab world, where a significant proportion of the population lives in low- and middle-income countries, or is made of refugees or migrant workers, existing disparities are expected to widen. What is urgently needed is for governments to rethink their collaboration models with non-state actors to ensure that UHC, equity considerations and social justice are at the core of health systems (WHO, 2020). The pandemic has reminded us that health is a basic human right and not a commodity and that the success of the efforts to contain it depends on protecting all segments of society. The time has come for governments to assume their role to protect this right for all by drawing on the different capacities in their societies.



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The views represented in this paper are those of the author(s) and do not necessarily reflect the views of the Arab Reform Initiative, its staff, or its board.