Elsevier

The Lancet

Volume 383, Issue 9914, 25–31 January 2014, Pages 343-355
The Lancet

Series
Governance and health in the Arab world

https://doi.org/10.1016/S0140-6736(13)62185-6Get rights and content

Summary

Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.

Section snippets

Background

Uprisings and protests in the Arab world have emphasised social and economic inequity, absence of political accountability, and concerns about government corruption. Although the optimism for more inclusive and effective governance throughout the region has now given way to concerns about the rise of patriarchal conservatism, civil war, and political instability in some countries, the demand for more inclusive and equitable government in the region has been heard. The toppling of regimes in

The role of governance in shaping health

To establish a causal pathway for governance and health, scholars have been divided about whether it is democracy or governance effectiveness that leads to improvements in health and human development. Although definitions of democracy vary and are subject to extensive debate, most studies relating democracy and health consider electoral democracy, as scored by the Polity IV project (panel 1), which is based on the competitiveness, openness, and level of participation in elections. These

Trends in health and governance

Overall, since 1970, health indicators in the Arab world have sharply improved with an average increase in life expectancy of 19 years—the largest gain among world regions, and an average reduction in infant mortality of 60 deaths per 1000 livebirths.15 In fact, five of the ten countries with the largest development gains since 1970 were Arab (Oman, Saudi Arabia, Tunisia, Algeria, Morocco).15, 41 Since 1980, adult mortality has been declining across the region, except in Iraq (appendix p 3).

Measurement of the relation between health and governance

Data for demographic, mortality, and governance trends in the Arab world have rarely crossed out of disciplinary silos in public health, economics, or politics (panel 1). For this paper, we built an extensive dataset for indicators related to health and governance in the Arab world (data available from authors on request). Our primary aim was to synthesise the literature on health and governance in the Arab world, investigate the associations between governance on mortality trends, and explore

Informing the reform agenda

Academic research is divided on whether it is democracy or effective government that leads to improved health. We cannot be any more conclusive about the causal mechanisms between governance and health in the Arab world. Our analysis shows that in the Arab world, democracy and mortality improvements are not associated; however, there does seem to be an association—worthy of further investigation—between government effectiveness and mortality improvements.

In view of the concerns about the

Threats to health during the Arab uprisings

The Arab uprisings, while advocating for increased political accountability, economic opportunity, and equity, have had immediate detrimental effects on health in the region. The conflicts that have accompanied or followed uprisings in Syria, Egypt, Yemen, and Bahrain have led to increased social divisions, migration, political violence, and disruptions in education and health-care provision. These recent challenges come on top of the prolonged conflicts and insecurity in Iraq, Somalia, and the

Improving governance and health

For the first time in the history of the Arab nations, a movement has galvanised to demand freedom and increase political inclusiveness and accountability. However, the initial hope for reform across the region has, in many places, been replaced by violence, fear, or a hardening of the traditional status quo. What the future holds for the Arab world is unclear. The trends shown here, and the published literature, suggest that focusing on building effective and inclusive governments in the

References (62)

  • HF Abdul Rahim et al.

    Non-communicable diseases in the Arab world

    Lancet

    (2014)
  • R Nakkash et al.

    Research and activism for tobacco control in the Arab world

    Lancet

    (2014)
  • O Dewachi et al.

    Changing therapeutic geographies of the Iraqi and Syrian wars

    Lancet

    (2014)
  • T Tell

    State formation and underdevelopment in the Arab world

    Lancet

    (2014)
  • M Cammett et al.

    The political economy of the Arab uprisings

  • R Kuhn

    On the role of human development in the Arab Spring

    Popul Dev Rev

    (2012)
  • R Grant et al.

    Accountability and abuses of power in world politics

    Am Polit Sci Rev

    (2005)
  • LL Tsai

    Solidary groups, informal accountability, and local public goods provision in rural China

    Am Polit Sci Rev

    (2007)
  • A Díaz-Cayeros et al.

    Traditional governance, citizen engagement, and local public goods: evidence from Mexico

    World Dev

    (2013)
  • A Diaz-Cayeros et al.

    The Politics of Public Spending—Part II. The Programa Nacional de Solidaridad (PRONASOL) in Mexico

    (2003)
  • R Lemarchand et al.

    Political clientelism and development: a preliminary analysis

    Comp Polit

    (1972)
  • M Loewe

    Pension schemes and pension reforms in the Middle East and North Africa

    (2009)
  • S Jabbour et al.

    The political, economic and social context

  • A Alesina et al.

    Fractionalization

    J Econ Growth

    (2003)
  • A Alesina et al.

    Ethnic diversity and economic performance

    J Econ Lit

    (2005)
  • J Drèze et al.

    The political economy of hunger

    (1990)
  • M Ross

    Is democracy good for the poor?

    Am J Pol Sci

    (2006)
  • E Mansfield et al.

    Democratization and the danger of war

    Int Secur

    (1995)
  • F Fukuyama

    State-building: governance and world order in the 21st century

    (2004)
  • J Gerring et al.

    Democracy and human development

    J Polit

    (2012)
  • E Huber et al.

    Development and crisis of the welfare state

    (2001)
  • Cited by (72)

    View all citing articles on Scopus
    View full text