Table 2 Health systems, political structures and COVID-19 situation in selected countries
Country | Health system characteristics | Political structure and health policymaking process | COVID-19 situation during early phase of pandemic (as of 31 December 2020) | References |
|---|---|---|---|---|
High-income countries | ||||
Bahrain | • Governance arrangement: The National Health Regulatory Authority (NHRA) oversees Bahrain’s healthcare system, regulating both public and private providers • Financing arrangement: Health expenditure as a share of GDP reached 4.7% in 2020. The Ministry of Health provides free healthcare to Bahrainis while private hospitals offer paid services. Out-of-pocket expenses account for only 20% of total health expenditures, indicating a strong safety net for the population • Service delivery: Multiple entities deliver healthcare services, with the Ministry of Health providing the bulk of subsidized care. A mix of public and private healthcare providers caters to the needs of the population | • Government type: Constitutional monarchy • Health policymaking: Healthcare development is guided by several mid- and long-term strategies and policy documents, including the National Health Plan 2016–25, adopted by the Supreme Council of Health; the National Health Regulatory Authority 2016–20 Strategy, emphasizing inspection and accreditation activities; and the Bahrain Economic Vision 2030, a long-term economic development and diversification agenda that seeks to modernize Bahrain’s healthcare sector | • Date of first recorded COVID-19 case: 24 February 2020 • % of COVID-19 cases out of the population: 5.34% • Total COVID-19 deaths: 352 • Case fatality rate (% of deaths of total cases): 0.38% | |
Kingdom of Saudi Arabia (KSA) | • Governance arrangement: Government has given high priority to the development of healthcare services which resulted in a well-established healthcare system that provides all citizens and residents with free healthcare services • Financing arrangement: Government is the primary funder of the healthcare system and has significantly increased its spending on the healthcare sector over the past few years. In 2020, the government allocated $US 39.2 billion for the health sector • Service delivery: The government is responsible for providing healthcare services. As of 2021, there were more than 75,000 hospital beds, which translates to 2.3 beds per 1000 people | • Government type: Monarchy, headed by the king, who is also the commander-in-chief of the military • Health policymaking: Health policymaking navigates a dynamic landscape, balancing adherence to global patient safety standards and international best practices with statutory regulations, cultural sensitivities and alignment with national health development strategies | • Date of first recorded COVID-19 case: • 2 March 2020 • % of COVID-19 cases out of the population: 1.03% • Total COVID-19 deaths: 6223 • Case fatality rate (% of deaths of total cases): 1.71% | |
United Arab Emirates (UAE) | • Governance arrangement: A comprehensive, government-funded health service and a rapidly developing private health sector that delivers a high standard of healthcare to the population. Healthcare is regulated at both the federal and emirate level. Public healthcare services are administered by different regulatory authorities in the UAE • Financing arrangement: Government allocates a significant share of the federal budget for the healthcare sector every year to provide quality medical services. The percentage of federal budget allocated to health was 7.3% in 2019 • Service delivery: Well-functioning healthcare system at primary, secondary and tertiary levels. The UAE has a top-tier healthcare system that is regularly ranked in the top 20 in the world with adequate resources including financial and well-developed health system infrastructure | • Government type: Elective monarchy formed from a federation of seven emirates. Each emirate is an absolute monarchy governed by a ruler, and together the rulers form the Federal Supreme Council • Health policymaking: The UAE’s public policy for healthcare focuses on developing organizational and legal frameworks based on best practices, and overhauling and upgrading the private and public sector health service capabilities. In addition, public policy action will set priorities for health services development within the sector | • Date of first recorded COVID-19 case: 29 January 2020 • % of COVID-19 cases out of the population: 2.08% • Total COVID-19 deaths: 669 • Case fatality rate (% of deaths of total cases): 0.32% | |
Middle-income countries | ||||
Jordan | • Governance arrangement: The Jordanian health system is governed by the Higher Health Council, which sets national health policy, regulates the sector and plans for equitable and high-quality services • Financing arrangement: Health expenditure in Jordan represents 8.44% of GDP. Public, military, private and university health insurance schemes cover the majority of the population • Service delivery: Jordan’s health system is a complex amalgam of three major sectors: public, private and donors. Key challenges include accessibility issues, service duplication, poor coordination and unregulated private sector, low private sector utilization, limited quality improvement programs, inefficient resource usage, poor management and an inadequate health information system | • Government type: A monarchy in which the king plays a dominant role in politics and governance. The parliament’s lower house is elected • Health policymaking: Health policymaking in Jordan is highly centralized, and local governments have no autonomy to formulate their own responses to the pandemic | • Date of first recorded COVID-19 case: 2 March 2020 • % of COVID-19 cases out of the population: 2.87% • Total COVID-19 deaths: 3834 • Case fatality rate (% of deaths of total cases): 1.3% | |
Lebanon | • Governance arrangement: Lebanon’s healthcare system is pluralistic and fragmented, private sector dominated, and curative focused. Existing structural challenges, economic crisis, civil unrest and Beirut Port Blast have propelled the system towards collapse • Financing arrangement: Private sector is the main financer of the health system. Public healthcare services receive limited resources from the government, particularly for primary and preventive care, while a significant percentage is spent on hospital-based care • Service delivery: Healthcare delivery in Lebanon is undertaken by a network of 134 private and 28 public hospitals in addition to various nongovernmental organizations providing primary healthcare in underprivileged regions | • Government type: A parliamentary democratic republic with direct parliamentary elections held every 4 years. However, after the 2009 election, no further elections were held until 2018 and then again in 2022 • Health Policymaking: Lebanon’s political system, characterized by a corrupt sectarian structure, has hindered healthcare sector development. The absence of political will and inadequate accountability mechanisms have contributed to insufficiencies in the healthcare sector, particularly during the crisis | • Date of first recorded COVID-19 case: 21 February 2020 • % of COVID-19 cases out of the population: 2.66% • Total COVID-19 deaths: 1468 • Case fatality rate (% of deaths of total cases): 0.8% | |
Tunisia | • Governance arrangement: The healthcare system is overseen by the Ministry of Health, which is responsible for developing and implementing national health policies, regulating the healthcare sector and planning for equitable and high-quality healthcare services. The Ministry also manages the National Health Insurance Fund (CNAM), which provides health insurance coverage to a significant portion of the population • Financing arrangement: Healthcare is financed through a combination of social health insurance, general government revenues and private spending. CNAM covers more than 80% of the population, while the non-contributory Assistance Médicale Gratuite (AMG) program covers poor households. Despite the existence of CNAM and government funding, out-of-pocket payments remain a substantial source of health expenditure, accounting for 36.6% of total health spending • Service delivery: Tunisia’s healthcare infrastructure is characterized by uneven distribution and resource disparities. This uneven distribution highlights the coastal–interior regional gap, leaving interior regions more vulnerable | • Government type: Tunisia, once a representative democracy, transitioned to an authoritarian state following the president’s suspension of parliament and rule by decree in 2021. The country’s political landscape is fragmented, with a deeply divided parliament hindering effective policymaking • Health policymaking: National public health policy is implemented by regional health directorates under the supervision of the Ministry of Public Health. However, the centralized management of public health facilities is reported to hinder responsiveness | • Date of first recorded COVID-19 case: 2 March 2020 • % of COVID-19 cases out of the population: 1.17% • Total COVID-19 deaths: 4676 • Case fatality rate (% of deaths of total cases): 3.36% | |
Low-income countries | ||||
Sudan | • Healthcare system governance: The Federal Ministry of Health oversees the Sudanese healthcare system in collaboration with other ministries and state health departments. Despite decentralization efforts, the system remains incomplete due to the inappropriate transfer of responsibilities to lower levels, resulting in low implementation efficiency due to weak capacity and resource constraints • Healthcare system financing: The former Sudanese government prioritized military spending over healthcare, leaving the current transitional government with a severely underfunded and fragmented health system, receiving only 1% of the budget. This underfunding has led to high out-of-pocket expenditures (66.95%), causing catastrophic financial hardship for 78% of households • Service delivery: Sudan’s healthcare infrastructure is severely lacking. When the COVID-19 pandemic began, the country had only around 500 intensive care unit (ICU) beds. Moreover, there were only 1.2 hospitals and 13.5 primary healthcare centres per 100,000 residents. The system is further strained by a shortage of healthcare professionals, inadequate supplies and logistics and severely understaffed and under-equipped health facilities | • Government type: Sudan’s political system is characterized by an authoritarian rule with the president and his National Congress Party (NCP) maintaining power through a combination of repression and inducements. This authoritarian structure has significantly impacted the country’s healthcare system and policymaking processes • Health policymaking: Health policymaking in Sudan is primarily driven by the Federal Ministry of Health (FMoH), which is responsible for formulating and implementing national health policies. However, the authoritarian nature of the government has limited the participation of other stakeholders, such as civil society organizations and healthcare professionals, in shaping health policies | • Date of first recorded COVID-19 case: 13 March 2020 • % of COVID-19 cases out of the population: 0.0056% • Total COVID-19 deaths: 1468 • Case fatality rate (% of deaths of total cases): 5.75% | |
Syria | • Governance arrangement: Syria’s healthcare system is fragmented due to the ongoing conflict and the absence of a central national authority. Multiple power structures have emerged, each with its own governing body responsible for healthcare provision. These structures vary in their effectiveness and coordination, hindering overall system management • Financing arrangement: Syria’s healthcare system has faced significant financial constraints even before the conflict. The limited resources available have been insufficient to meet the growing demand for healthcare services, leading to low government expenditure on health as a percentage of gross domestic product (GDP) and per capita. This shortage of funding has resulted in high out-of-pocket expenses for patients • Service delivery: The Syrian healthcare system has been severely impacted by the conflict, with many public hospitals damaged or destroyed. Approximately 40% of public hospitals are either partially or fully functional, severely limiting the capacity to provide essential healthcare services. Additionally, the overall healthcare infrastructure is lacking, with insufficient hospital beds and inadequate supplies. This situation has been exacerbated by the COVID-19 pandemic, which has further strained the already overburdened system | • Government type: Syria is a unitary multiparty republic with a one-chamber legislative body, headed by a president. However, the country’s ongoing conflict has fragmented governance structures, leading to the emergence of multiple power centres in different geographical regions. This political division has resulted in a patchwork of health systems, each with varying capacities and structures, affecting the delivery of healthcare services to the Syrian population • Health policymaking: The complex and dynamic nature of Syria’s conflict has disrupted traditional healthcare governance structures, leading to a situation in which policymaking is influenced by the shifting power dynamics and territorial control within different regions. This fragmentation has hindered the development and implementation of coherent national health policies, affecting the equitable and efficient delivery of healthcare services to the population | • Date of first recorded COVID-19 case: 22 March 2020 • % of COVID-19 cases out of the population: 0.064% • Total COVID-19 deaths: 5373 • Case fatality rate (% of deaths of total cases): 6.2% | |
Yemen | • Governance arrangement: Yemen’s healthcare system is structured at three levels: central, governorate and district. While the central Ministry of Health oversees policy and strategy development, governorate and district health offices manage service delivery, including planning, budgeting and human resource management • Financing arrangement: Yemen’s annual total health expenditure is among the lowest globally. Yemen’s healthcare system heavily relies on external funding, with implementing organizations playing a primary role in service delivery. This over-dependence on development partners has exacerbated challenges, as external funding has declined significantly, leaving the system vulnerable to threats such as COVID-19 • Service delivery: The ongoing conflict has severely disrupted Yemen’s healthcare system, with only 50% of facilities fully functional. This has led to critical shortages in essential medicines, staff and equipment, compromising access to basic healthcare services for three quarters of the population. The conflict has also exacerbated health challenges and weakened governance in the healthcare sector | • Government type: A complex and fragmented governance structure, with no single entity exercising full control over the territory. The central government has been effectively paralysed since the outbreak of the civil war in 2015, and various armed groups and unelected officials hold sway over different regions. This fragmented political landscape has significantly hindered the development and implementation of effective health policies • Health policymaking: The fragmented governance structure and weak institutional capacity have severely constrained health policymaking in Yemen. The absence of a central authority capable of coordinating and implementing health policies has resulted in a patchwork of approaches across different regions. Additionally, deficiencies in the health information system hinder evidence-based decision-making and resource allocation, further impeding effective policy formulation | • Date of first recorded COVID-19 case: 10 April 2020 • % of COVID-19 cases out of the population: 0.007% • Total COVID-19 deaths: 610 • Case fatality rate (% of deaths of total cases): 29% | |