Revolution is a process of rebirth, a unique opportunity for the assertion of a new national identity in the wake of unpopular and oftentimes disgraced rule. In lieu of the policies of previous administrations, the newly-instated governments of post-revolutionary countries largely seek to reinvent national identities through the implementation of novel legislation reflecting the values held by successful revolutionary factions. In the wake of political turnover, entire institutions are remolded to assert these values; healthcare systems are often conspicuous recipients of this remodeling. To better understand the impact of political revolution on sociocultural value assertion in post-revolutionary states, this article seeks to explore said values underpinning the motivations for revolt, especially as these are reflected in the pre- and post-revolutionary health policies and systems of the three North African nations of Tunisia, Libya, and Egypt. To this end, I first provide brief justification for the use of healthcare systems as a means of analyzing value assertion in these three countries; I then explore the unique circumstances contributing to the Arab Spring revolutions in each nation and how these impacted the subsequent reformation of each national health system.
Sparked by the protestant self-immolation of a beleaguered Tunisian street vendor, and culminating in the largely violent political revolution of several Middle Eastern and North African (MENA) nations, the Arab Spring launched an already fraught geopolitical region into an era of renewed turmoil and uncertainty. Large-scale protests erupted across the region, sometimes escalating into civil war, and the political figures and governments of Tunisia, Libya, and Egypt, among other nations, were replaced. Though many avenues exist for the implementation of the values inherent in these newly-instated governments, perhaps the most choice channel for the realization of such ideals is through the healthcare system of these nations—profound value-laden questions are often debated within this field, including: who, if anyone, is entitled to and excluded from care; how is this care allocated, delivered, and funded; and who are the major stakeholders in such a system? These bioethical questions are especially prominent in the post-revolutionary MENA states, as the aftermath of revolution affords a unique opportunity to enact policy affirming widely-supported yet previously unacknowledged or repressed cultural values. It is therefore pertinent to analyze the health systems of these nations as reflections of the cultural norms and values of the revolutionary populace.
In one such nation, Tunisia, the country revolted against French colonial powers in an armed struggle to earn its independence in 1956. The subsequent drafting of the national constitution incorporated a socialist model of government adopted to provide for the equality of all. Among the most valued rights in the newly-independent Tunisia were equal access to education and health; so valued were these rights, in fact, they consumed one-third of the total government budget for nearly two decades following the revolution for independence [12]. Funds were created for both government and private employees, increasing the number of insured individuals [11].
The socialist model quickly failed, however, as government interference in agrarian policies and workers’ unions created tension between the working class and the government. This unrest resulted in the eventual ousting of President Bourguiba and his replacement with the authoritarian General Ben Ali, who enacted sweeping reform. Increased government spending in the social sector motivated Ben Ali to implement “user charges” for the once-free public healthcare system, and as funding continued to dwindle the privatization of medical practice became more commonplace. As a result, out-of-pocket health expenditures increased dramatically; while government spending on health decreased from 45 to 26 percent between the 1970’s and 2008, household spending on health increased from 36 to 45 percent over the same period [12]. Additionally, government intervention in labor resulted in widespread unemployment and civil unrest largely influenced by the erosion of human rights and a long-held nationalist identity; Ben Ali’s policies exerted individualistic principles that violated many Tunisians’ sense of communitarianism. Public outrage ensued and revolution was quick to follow, resulting in the ousting of Ben Ali and the implementation of a democratic system of government favoring communitarianism and social support to counter the decades of oppressive authoritarianism.
Following the revolution, civil service organizations (CSOs) in Tunisia have lobbied to incorporate explicit terminology in the constitution delineating the role of government in ensuring health as a human right. There is widespread appeal in reversion to the pre-authoritarian social ideals of government-supported health systems which would provide access to healthcare for all Tunisians. Critics of publicly-funded health systems fear heavy-handed government intervention similar to that of the previous authoritarian regime. Additionally, the current governing Islamist party considers a socialist-style approach to be intractable, opting instead to fund public health institutions through a communitarian donation system that closely mirrors the zakat, or charity, pillar of Islam [8]. Opponents of this system argue that such a structure fails to adequately address health as a fundamental right, a designation many feel should be included in the national constitution, and that the system relies too heavily on faith-based organizations instead of secular institutions with the risk of excluding certain religious minorities, namely Christians and Jews. Despite differing opinions as to the implementation of health policies, most parties agree on the importance of health and are striving to make it equally accessible for all, likely a result of the newly-revitalized nationalist sentiments many Tunisian citizens hold.
The revolutionary situation in Libya mirrors many of the circumstances preceding the Tunisian uprising. Unfair policies undercutting the working class resulted in a coup d’état in 1969, in which King Idris I was replaced with military leader Muammar Gaddafi, who assumed dictatorial control of the nation and converted the previous monarchical government into a republic built upon “freedom, socialism, and unity” [6]. As in Tunisia, the new government emphasized equal access for all individuals to education and healthcare; the government assumed responsibility for the funding of these programs and allocated resources to maintain schools and public hospitals. However, the ideal of equality quickly disintegrated under Gaddafi. Whereas Tunisians were largely nationalist and this was reflected in the health system in that country, Libyan citizens were distinctly tribalist, leading to the establishment of hospitals in certain localities that prohibited care for ethnic minorities. Most notably, the Toubou and Berber peoples were barred from treatment in private and even public hospitals across the nation and were treated as foreign citizens in Libya and stripped of their rights [9]. Under Gaddafi’s rule, such erasure and silencing was widespread and promulgated by those within his party.
The violations of human rights and the quashing of minority tribal identities, as well as widespread political repression and corruption, led to the uprising of 2011 in the midst of the Arab Spring. Unlike the largely successful Tunisian Revolution, the uprising in Libya has escalated into prolonged civil war and tribal conflict. Following Gaddafi’s death in October 2011, factions of revolutionaries laid separate claims to power and remained in deadlocked contest for governmental control; not until December 2015 did the Government of National Accord (GNA) emerge as the Libyan unity party with unanimous UN Security Council support [5].
A national conference was called to present recommendations for the restructuring of the Libyan health system in a manner that incorporated national values and ideals. Most of the policies reflect an aversion to individualism and tribalism, calling instead for communitarian approaches to health funding and service delivery. While few participants called for a completely government-funded health system, most agreed that a reversion to the social insurance model of the 1970’s is appropriate given the Libyan ideal of unity, or solidarity. However, there is opposition against the implementation of a mutual employer-employee tax (Bismarck) model of funding at the federal level, named for the Prussian chancellor who devised such a tax-based welfare state in an effort to unify Germany in the early 19th century [10]. Though unification is a worthwhile endeavor given tribal groupishness, detractors to the Bismarck model point out that such a system could lead to wasted funds through the introduction of private, third-party insurance company intermediaries [3]. Religious tensions are also likely to arise as the Islamic view, predominant in Libya, values health but does not consider it a fundamental human right for which the government should provide funding, much as in the Tunisian debate. Nevertheless, there is widespread support for universal coverage for free and basic healthcare, and the government is expected to play an integral role in the funding and allocation of related resources for all Libyans, independent of tribal or ethnic relation.
The Egyptian Revolution of 2011 shares many aspects with the two aforementioned movements in Tunisia and Libya. Following the assassination of Anwar Sadat in 1981, Hosni Mubarak claimed dictatorial power of the Egyptian government. Stationed along the Nile, Egypt had long required a strong social cohesion to maintain control of important trade routes and ports; however, Mubarak’s rule largely undermined this collectivist identity to prevent insurrection. This oppression manifested in the degradation of public infrastructure and the violation of human rights. Over Mubarak’s 30-year rule healthcare systems were left largely unaddressed, with funding instead diverted for government cronyism and the maintenance of an authoritarian police state [4]. Though health was a constitutional right, public health infrastructure largely failed to adequately provide care and out-of-pocket expenses soared to 97.7% of household health expenditures by the eve of revolution in 2011 [1]. Exhausted from persistent economic burdens imposed by Mubarak’s legislation and frustrated with the repeated oppression of civil liberties, the Egyptian people took to the streets and demanded his resignation.
What followed was a prolonged period of instability. The Supreme Council of the Armed Forces assumed command before being ousted and replaced by Mohammed Morsi, who was also subsequently ousted after decreeing himself above the law and seeking to implement strict Islamist policies. Stability was finally enacted with the election of Abdel Fattah el-Sisi and the referendum vote to approve a new national constitution. These latter aspects are important as they highlight the importance of social cohesion in Egyptian society—fundamental Islamism was rejected for fear of disunity, and popular vote was used to enact the governmental changes Egyptians had been longing to see. It is interesting to note that the Egyptian constitution contains reference to health as a human right, the only nation in this analysis to do so, and it is also the only nation in this analysis to have rejected fundamental Islamist policies which do not recognize health as a human right. Prominently, the constitution reflects desires for social cohesion and stability in its guarantee of the provision of healthcare to all Egyptians for all diseases, as well as the education of all university students in human rights [2]. These clauses are demonstrations of the reinvigorated Egyptian ideals of collectivism and solidarity.
Throughout this analysis, several themes have become apparent. Most clearly displayed is the motif of resurgent nationalism and social unity in the wake of oppressive and divisive authoritarian rule. Though the nations differ in the implementation of health policies reflecting revitalized collectivist ideologies, each exerts these values in their respective health systems. It is remarkably clear that these values are derived from the revolutionary experience. Steven Lukes writes in his book on moral relativism that people’s values “make sense to them over time of the choices they make” [7]; the camaraderie and unity required for successful political revolution are apparent qualities in the post-revolutionary health systems of these nations. Lukes also discusses the plurality of values that can exist even among people with shared history and experiences [7]. This is evident in the Islamic factions’ refusals to accept health as a human right in national constitutions, thus endangering the certainty of provisional health services being made available to all citizens, even if health is highly valued within the framework. Still, there is a consensus amongst most parties as to the fundamental importance of health; the esteem with which it is regarded in these post-revolutionary nations is a testament to the improved lifestyles for which citizens tirelessly fought, and the health policies of these nations serve to codify and solidify the systems and values that will continue to benefit generations to come.
References:
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