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The coronavirus pandemic has revealed fundamental flaws in the systems of governance and the delivery of basic social services to the people around the world. The ongoing health crisis especially exposed the weakness of healthcare systems in the Asia-Pacific. In the case of the Arab region, the unequal distribution of healthcare services is coupled with the fragility of the existing political, economic and social systems. The pandemic highlighted the limited capacities of health structures, with their inability to effectively contain the spread of the virus and minimize fatalities.
With these systems in place, Arab countries were unprepared to face a global health crisis. The latest data available from 2016 show that Arab states spend an average of 5% of their gross domestic product (GDP) on health, which is below the overall average for low and middle-income countries (5.4 percent). Due to continuing foreign political and military intervention in the region, Arab states tend to privilege national security expenditures over human security. Despite their poor track record of investing in public health, imports of arms by countries in the Middle East have increased by 61% in the last 10 years, constituting 35% of the total global arms in the last five years. This systemic under-investment in providing basic social services gives rise to more pronounced negative impacts, especially in times of crisis, as was witnessed during the pandemic.
Persisting Inequalities in the Arab Region
Even before the pandemic, vulnerable and marginalized groups lacked access to health services, despite the global increase in wealth, knowledge and awareness invested in health. Health indicators were able to exhibit considerable progress in the delivery of services by national healthcare systems, but progress remains unequally distributed in the region. There remains an ever-widening gap between the distribution of health services among socioeconomic groups and in the urban and rural areas.
Inequalities in health services are not restricted to the national level, and there are profound disparities between Arab states themselves when it comes to access to healthcare. For instance, while the region has an average of 20 physicians per 10,000 population, there is a stark difference within the high-income, middle-income and low-income countries. High-income countries have an average of 28.7 physicians, middle-income with 16.1 and low-income with 7.9 per 10,000 population. While high-income Arab states have a ratio even better than the global mean physician density, low-income countries have way less than the ideal.
Additionally, many countries, such as Syria, Yemen, Iraq and Palestine, that were witnessing conflicts or war even prior the pandemic, faced an additional, heavy burden on the already weakened socio-economic infrastructure, contributing to further deterioration of living standards.
The Impact of COVID-19
As of July 2021, the number of COVID-19 cases in the Arab region has reached 11 million, with more than 200,000 deaths. The rising number of cases is caused by the inaccessibility of health services, especially for the vulnerable and marginalized sectors. Public health institutions were not well-equipped to respond to the health crisis, especially during outbreaks. Limited supply of ventilators needed for critical COVID-19 cases has increased preventable deaths. The overburdened health sector also lacked the capacity to restore regular health services in order to treat non-COVID-19 cases.
The COVID-19 pandemic also led to significant socio-economic repercussions in the region. There was a loss of more than 1.7 million jobs in 2020, increasing the unemployment rate by 1.2% and further shrinking the middle income class by forcing 8.3 million people into poverty. The most severe consequences of the crisis were felt among vulnerable groups, including women, young adults, refugees, informal workers (comprising the majority of the labor force), who have no access to health insurance and social protection programmes.
Social protection programmes in the Arab states remain weak and fragmented, excluding marginalized groups such as migrants, informal workers and the unemployed. For instance, migrants in Lebanon, including Palestinians, Sri Lankans, Indonesians and Syrians are particularly at risk as they are ineligible to enrol in the National Social Security Fund (NSSF). These groups were forced to rely on their meagre savings for survival (if there are any) or to disobey health measures in order to maintain a daily source of income to pay for basic needs.
Moreover, access to social safety nets is still very limited and the rare systems in place are often governed by weak institutions. The situation is all the more difficult in countries witnessing violent conflicts where the lack of access to health, social services and information are profound.
With past and ongoing conflict, Arab governments lack the capacity to establish universal social protection floors.
COVID-19 Response of Arab States
In light of the clear deterioration of living standards due to instability in certain Arab countries, there is a record high dependency on Official Development Assistance (ODA) for the delivery of basic social services. Despite the various projects and programmes undertaken by donor countries and international finance institutions (IFIs), the provided assistance is far from sufficient in the face of the compounding crises and challenges faced by the region. Humanitarian programmes often tackle short-term relief in conflict-affected states, casting a shadow over capacity-building and sustainable development projects. This subsequently forms a vicious cycle reinforcing dependency and the perpetual presence of weak state institutions.
In 2020, net bilateral ODA flows from donor countries to low-income countries actually decreased by 3.5% in real terms compared to the previous year, when net bilateral ODA to lower-middle income countries showed an increase of 6.9%. Ironically, net ODA in 2020 to upper-middle countries increased by 36.1% while net ODA flows to high-income countries tripled. These figures, coupled with the increase in the portion of loans in ODA would suggest that the growth in ODA flows in 2020 is attributable to loans to middle-income countries. This clearly highlights inequalities in relation to ODA distribution, as well as the lack of a comprehensive strategy for low-income countries to respond to the crisis.
In Syria, the government responded to the pandemic by redirecting resources to respond to COVID-19 related needs and requesting support from agencies such as the United Nations High Commissioner for Refugees (UNHCR). UNHCR Syria’s COVID-19 appeal of USD 4 million was completely funded in order to help cope with the crisis and pre-existing fragility of the state. However, it is difficult to affirm that the assistance was appropriate or fairly distributed geographically due to the on-going conflict in the country and the lack of a unified system of governance on the Syrian territory.
In Palestine, banks were requested by the Palestinian Monetary Authority (PMA) to postpone loan payments for at least four months for all individuals and businesses. Additionally, a USD 300 million Small and Medium Enterprises (SMEs) fund was launched by the PMA to offer soft loans to those enterprises that have suffered from the crisis. Targeted measures implemented by the government include the distribution of one-off payments to some 40,000 workers affected by the pandemic, and the provision of financial assistance for 125,000 vulnerable households. However, with the current violence and conflict in Palestine inflicted by Israeli Occupation forces, there is a need for urgent humanitarian assistance.
With the estimated USD 152 billion loss in real GDP of the region and grossly insufficient ODA, low-income countries are turning to IFIs to fund their COVID-19 response projects. However, with this turn to IFIs, they are subjected to loans, debt, and conditionalities that only contribute to further fragility and vulnerability. Nevertheless, different methods and emergency programmes have been adopted by Arab states in order to cope with the socio-economic impacts of the pandemic on vulnerable groups, especially those in conflict-affected areas.
In Syria and Yemen, the lack of testing capacity has caused months of under-reporting and unclear data about the virus’ real spread. The number of officially confirmed cases in Yemen as of April 2021 is only 4,798, which is most probably far from reality, considering the total population of 29 million. Moreover, more than 15.4 million people in Yemen urgently needed assistance to access WASH services in March 2021.
In Iraq, the government tried to curb the pandemic’s impacts by adopting different strategies and shifting its priorities. The Central Bank of Iraq decreased its reserve requirements and declared a moratorium on the settlement of interests by SMEs, in addition to the implementation of a cash transfer programme of IQD 300 billion (or approximately USD 254 million) to families of private sector workers that were not given salaries or benefits from the government during the crisis. Exceptional paid leave for women employees was also granted.
These countries also received grants and loans from various financial institutions. Due to immediate need of aid, relief from the World Bank in the form of COVID-19 Emergency Response Projects adopted emergency guidelines that serve to expedite procurement processes. Under the bank’s COVID-19 fast-track facility, it was able to provide around USD 1 billion to the region. However, shorter bidding times, simplified agreements and limited oversight were adopted by the bank to provide these funds, which can subject the recipient countries to further risks.
In Lebanon, the severe health and economic crisis limited the government’s capacity to strengthen its institutions and support the livelihoods of the people in the country. Despite this, a USD 797 million stimulus package was launched by the government to provide assistance to daily workers in the public sector, health care workers and farmers, as well as provide subsidized loans for SMEs. The World Bank also implemented the Emergency Crisis and COVID-19 Response Social Safety Net Project amounting to USD 246 million for emergency cash transfers and access to social services for extremely poor and vulnerable households. However, the bank states that the Lebanese government has not yet submitted the required paperwork to begin implementing the project. At the same time, the World Bank still lacks compliance with effectiveness conditions, delaying project implementation and risking non-compliance with development effectiveness principles and human rights.
Other programmes, such as a cash assistance distribution plan intended for the poorest families, and an economic rescue plan, were officially approved by the Parliament in April 2020. To finance these programmes, a USD 10 billion aid from the International Monetary Fund (IMF) was applied for, which is pending for approval. However, the implementation of the cash assistance distribution plan remains unclear, and is probably with limited effectiveness given the freefalling of the Lebanese Pound currency and its weak government institutions. Similarly, the government has neither initiated nor implemented any crucial reforms in support of an economic rescue plan, hindering the much-needed launch of the programme.
The pandemic was an unexpected phenomenon, for which no government was ready for. In the Arab region, the underfunded health sector was incapacitated to respond to COVID-19. Fragile and conflict-affected states were especially unprepared as their scarce resources were already utilized or mobilized in responding to and recovering from previous crises. In this context, there was an urgent need for financial aid and humanitarian assistance in order to provide basic medical services and equipment to vulnerable populations.
Likewise, the adoption of different relief projects can eventually add to the burden of loans and debt in already struggling economies. Conditionalities imposed by the IFIs can also contribute to further fragility with the politicization and corporatization of aid in the region. Moreover, when projects are actually adopted, they are often not implemented according to human rights and transparency principles.
Even so, a clear gap remains between actual needs on the ground and the amount of resources provided by national governments, donor countries and IFIs. It is also difficult to say that development effectiveness principles are actively adopted in these disbursements. With the existing fragile and fragmented state of governance in some Arab states, COVID-19 response remains insufficient and recovery still challenging. In this regard, there is a need for a more comprehensive and effective approach to ODA disbursement in fragile, conflict-affected contexts to initiate inclusive, sustainable relief in the aftermath of the coronavirus crisis.
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