Bulletin of the World Health Organization

Will the Arab Spring bring better health to Egyptians?

Parliamentary elections in Egypt this month look set to change the political landscape. Former member of parliament and equity campaigner Hoda Rashad tells Fiona Fleck why the country’s public health programmes need to take a social justice approach.

Courtesy of Hoda Rashad
Hoda Rashad

Hoda Rashad is director and research professor at the Social Research Center of the American University in Cairo, Egypt. She serves on several councils in Egypt and technical advisory panels for United Nations agencies. She obtained her Bachelor’s and Master’s degrees in statistics at Cairo University in 1971 and 1974, and a Doctor of Philosophy at the London School of Hygiene and Tropical Medicine in 1977. From 2005 to 2008, she was a member of the Commission on the Social Determinants of Health established by WHO and served on the Senate, one of the two parliamentary bodies in Egypt, until earlier this year.

A: How is the Arab Spring affecting public health in Egypt and across the Middle East?

Q: Today we are in a period of transition, we need to establish new institutions and accountability mechanisms. It is a struggle to continue functioning and providing the usual public health services, but we are trying to keep business as usual. I don’t expect changes in public health until a new president is elected, which could be as late as 2013.

Q: Why do you believe “health equity” is essential in government policy?

A: The health equity approach maximizes the benefits of health services for the people who are most in need. In Egypt, we currently take a health systems approach, which allows you to see the big picture, but not the inequities in different social groups or the structural determinants beyond the health system, such as unemployment, lack of education and poverty. Also, some social groups are completely hidden, such as people living in squatter areas. They are mixed up with other urban population groups. We know about mortality and a few disease indicators for infants and young children, but we have no idea about the cumulative effect of deprivation and how it hampers their health and development.

Q: Will the call for freedom and democracy of the Arab Spring translate into better health for Egyptians and people in other countries in your region that are now in transition?

A: Definitely, I am sure it will translate into better health equity and therefore better health overall; it’s not just about the material living conditions. More freedom will have an impact on health, but to maximize that impact, government sectors need to be more aware of health when they adopt new policies. Good policies are not enough. We tend to look at the impact of policies on the average citizen. We tend to treat people equally, giving them equal access without realizing that the most disadvantaged people have difficulty benefitting from these good policies. We need to work more on maximizing both the impact of health programmes and of social programmes on health.

Q: Your call for health equity is not a call for a welfare approach but for social justice, what is the difference?

A: A welfare approach is when you feel sorry for disadvantaged people and you try to relieve their pain by giving them money and free services. But if you believe that those individuals have been deprived of the right to be healthy, to earn a living and benefit from health services, rather than giving them cash handouts, give them new opportunities in training, education, employment and security. Recognizing their right to health and your duty to provide this is the social justice approach.

Q: So, universal access to health-care services is not enough?

A: Even if you have really good health-care services and everyone has access to them, the key challenge is bringing about a social movement, a human development movement. At present, in our efforts to improve people’s health and well-being, we are very much health-systems driven, rather than taking an approach that involves the whole of the government including the health system. You need an overall government approach, which means that the whole government is accountable for health equity and not just the health sector because the health sector cannot do it alone. This health-in-all-policies approach is rather limited in our region and still needs to be embraced, although some countries are starting to talk more about equity than before and their health sectors are listening attentively. This is the case not only in our region: many developing countries share this in common. A few countries are taking up this approach: Chile, Finland, the Islamic Republic of Iran, Sweden and the United Kingdom. I see their public health strategies and recognize their true concern with equity. Morocco and Tunisia are talking more about equity than others; in their strategies they discuss equity, but they need to take further steps to adopt a health-in-all-policies approach to health. They need to bring in other social sectors and to push to the forefront some of the invisible inequities.

Q: Looking ahead, how could the Arab Spring affect the role of women?

A: Girls and women in our country and across the region have been very much involved in the battle for social justice: they have contributed to this on an equal footing with men. However, we are in a period of transition and it seems that forces adopting a misguided interpretation of Islam may be gaining power and could jeopardize the hard-won progress we have made in gender empowerment. Why? First, while traditional conservative values have their place in our societies there is a risk that their proponents will gain too much influence and, second, there is a risk that gender empowerment may become tainted, as it might be associated with the previous leadership. Yet in recent years, we have made progress in improving women’s health. Maternal mortality has declined considerably now that reproductive health services are included in the primary health care package. Breast cancer is receiving a lot of attention. Family planning programmes are receiving a great deal of attention and female circumcision [official WHO term is female genital mutilation] is on the decline.

Q: What is the Egyptian National Council for Women?

A: The National Council advises the government on policies that affect women and it monitors the status of women. It has contributed to significant legislative changes in family status law and has helped to mainstream gender in our country’s five-year development plans. It supports many initiatives for female-headed [single-parent] households and contributes to strategies for increasing female economic participation. It is also developing a strategy for addressing violence against women. But no one body can empower women alone. Now, because of its association with the previous leadership, the Council is trying to find its footing in the new situation. It’s still there and, to its credit, the transitional government has recognized the importance of this body. As members of the Council, we have committed ourselves to our advisory and monitoring role. In the transition phase, we hope that this progress will be protected. We will certainly do our best to protect it.

Q: Which public health programmes for women could be jeopardized by increased power for Islamic conservative groups?

A: Conservative Islam in Egypt is very supportive of the reproductive role of women and their contribution to family welfare and of the public health programmes supporting this, including family planning programmes for health reasons. The programmes that may be at risk are those seeking gender empowerment and that emphasize individual rights, such as the call for further reform in family status law or special female quota in the parliament.

Q: What kind of public health programmes are in place in Egypt that tackle social factors? Are these likely to change, given shifting power in the country?

A: We have a primary health care model that includes many community-based initiatives. These programmes are unlikely to change and may indeed be strengthened by a new political establishment. However, primary health care is very much applied as a medical model and not one that reflects a community participatory approach and an intersectoral model so its effect on health, particularly the health of disadvantaged groups, will be limited unless we adopt an equity approach in our social policies.

Q: Are there specific public health programmes that could be targeted by the new authorities? Which public health programmes were closely associated with the previous leadership in Egypt?

A: I don’t believe there will be changes to the current programmes. Maybe more funds will be allocated for health. However, the framing of health equity as a priority and as a whole-of-government approach is not an expected result of the Arab Spring. We still need improved measurement and analysis, advocacy and a more informed public to push the health equity agenda.

Q: The first Arab Human Development Report in 2002 highlighted a lack of democracy and freedom in the Middle East as an impediment to development. Are the current changes the ones you and other contributors envisaged at the time?

A: These are the changes to which we aspired; without them we will never achieve the progress our country deserves. However, many of us, including myself, did not expect the change to be through a revolution of the kind seen earlier this year. We expected a gradual process of reform. Unfortunately the process was too slow and failed to respond to public demand and to a generation’s outcry for its right to a better future.