Government Responses Toward the Coronavirus Crisis: A Comparative Analysis of Egypt, Turkey, and Saudi Arabia

Introduction: The role of governments in managing the COVID-19 pandemic crisis is what determines the outcomes in each country, among other significant factors.[i] This paper explores how government interference over the past few years has affected different government’s capacity to deal with the current coronavirus crisis as well as how their current interference will affect their future ability to deal with similar challenges.

The healthcare sector needs more than short-term government intervention; the intervention should be long-term and goal-oriented in order to make sure that problems are solved. However, some factors play a significant role in shaping government intervention, amongst which is the experience in dealing with previous epidemics and the political economy of the state. 

This paper tackles the topic by comparing three countries from the MENA region: Egypt, the Kingdom of Saudi Arabia (KSA), and Turkey. By comparing each government’s response, the paper argues that the political economy and previous similar healthcare experiences play a role in determining how each country responds to the coronavirus crisis.

These countries have significant differences in their regime type, the extent and nature of their social-economic status, and the diverse roles governments have played in the healthcare sectors. These roles have affected their crisis management and response toward the coronavirus crisis.

It is early to make an objective evaluation of government responses as the crisis has not fully unfolded. However, tracking government responses and comparing them to one another is a useful strategy to reach solid evidence regarding the best policies and strategies for coronavirus crisis management.

Traditionally, government intervention in the healthcare sector can take three forms:  financing, regulation, and delivery. The community and private sector both contribute to building healthcare systems.  However, in all cases, government intervention is a necessity in the healthcare sector, though the extent and content of this intervention may vary from one country to another.

These countries have significant differences in their regime type, the extent and nature of their social-economic status, and the diverse roles governments have played in the healthcare sectors. These roles have affected their crisis management and response toward the coronavirus crisis. 

It is early to make an objective evaluation of government responses as the crisis has not fully unfolded. However, tracking government responses and comparing them to one another is a useful strategy to reach solid evidence regarding the best policies and strategies for coronavirus crisis management.

Traditionally, government intervention in the healthcare sector can take three forms: financing, regulation, and delivery. The community and private sector both contribute to building healthcare systems. However, in all cases, government intervention is a necessity in the healthcare sector, though the extent and content of this intervention may vary from one country to another.

Why is Government Intervention in Healthcare Essential?

There are at least two reasons for intervention. The first reason is “market failure” in the healthcare sector where market mechanisms are unable to deliver the required product or service to the customers efficiently. In the healthcare sector, medical care providers hold privilege over patients by enabling them to determine prices and medical procedures, and, at the same time, patients do not have sufficient medical information to allow them to compare and select what they really need.

 This information asymmetry is one of the central causes for market failure which is a classical cause for government intervention in any sector. In every country, government intervention to fix market failure may take a minimal form like in the United States, a more extensive shape in the form of regulated competition like in the case of Germany and the United Kingdom, or the shape of a more extensive intervention like in the case of Cuba. 

The second reason for government intervention is to achieve Universal Health Coverage (UHC) for all citizens. Government intervention is essential to make sure that all citizens can obtain proper treatment at an affordable cost. Many segments in the society may receive insufficient treatment or no treatment at all because of their social, economic, or geographic location. In democratic countries, promising to provide good quality healthcare at an affordable price is one of the ways through which politicians may gain more votes.

 

In non-democratic regimes, public services are provided at a low cost in exchange for citizen non-interference in politics such as in the Arab states of the Persian Gulf.

In the Turkish constitution, article 56 indicates that the state shall regulate a central planning entity to regulate healthcare and supervise the public and private health sector and general health insurance.3 Article 18 in the Egyptian constitution states that the state guarantees support for public health facilities and is committed to establishing a comprehensive healthcare system, and is responsible for improving the conditions of healthcare providers.

4 In KSA, article 31 in the constitution states that the Kingdom shall provide healthcare for every citizen.5 In short, the above mentioned constitutions decree that it is the governments duty to intervene in the healthcare sectors, though not on equal standards. 

Who was Prepared Before the Crisis?

Three factors affected the efficiency of the government in handling the coronavirus crisis: the nature of the political economy, the degree of government intervention in the healthcare system, and previous experience in managing similar crises. 

The extent of the economic development and financial resources available shape the government’s role. Figure one shows the domestic general government health expenditure per capita indicator. The graph reveals that Saudi citizens receive more healthcare expenditure than people who live in Turkey or in Egypt. The rate of this increase in KSA was remarkable from 2010 to 2016. KSA had double government health expenditure per GDP (1800$/capita) than Turkey (917$/ capita).

 However, in the examined area, Turkey showed a sustainable increase in this indicator while KSA showed significant variation. This indicates that the Turkish government found a way to make healthcare financing sources sustainable while in KSA financing was affected by a drop in oil prices in 2016. Lastly, though Egypt had almost double its government spending per capita (From $99 to $200), there was still a gap between it, Turkey, and KSA, and this gap continued to increase over time. 

 

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Figure 1: Domestic general government health expenditure per capita, PPP (current international $) – Turkey, Saudi Arabia, Egypt, Arab Rep 

6 Three factors affected the efficiency of the government in handling the coronavirus crisis: the nature of the political economy, the degree of government intervention in the healthcare system, and previous experience in managing similar crises 5 According to the previous indicator, individuals in KSA were receiving more government health expenditure before the crisis. However, if we add domestic general government health expenditure as a percentage of general government expenditure, more data will be revealed concerning the government’s role. 

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Figure 2: Domestic general government health expenditure (% of general government expenditure) – Turkey (Blue), Egypt (Green), Arab Rep., Saudi Arabia (red)7 . 

Figure 2 reveals that over the examined period from (2000-2016), Egypt had the lowest percentage of government health expenditure and the percentage decreased over time as well (from less than 7% to around 4.5%). On the contrary, Turkey showed a significant increase over the same period with its peak in 2009 with 11.6%, while KSA’s government health expenditure showed variation over time. 

If we put both indicators together, we can conclude that: First, although Egypt doubled its government health expenditure per capita, the government showed signs of decreasing commitment toward heath expenditure as part of its government’s expenditure.

Second, KSA still showed variations, mostly related to oil prices, with a gradual increase starting in 2010.

Third, the Turkish governments showed a remarkable increase in the examined period with less fluctuation especially after 2004.

Interestingly, when comparing Turkey’s and Egypt’s governments, both countries were almost at the same level of government health expenditure in 2000 at almost 7%, but over the years, the gap between both countries increased, denoting different priorities for both governments and different levels of government intervention in the healthcare sector. 

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Figure 3: Domestic general government health expenditure (% of current health expenditure) – Turkey, Egypt, Arab Rep., Saudi Arabia 8

Domestic general government health expenditure, represented as a percentage of the current health expenditure, reveals the extent of government health expenditure from all health expenditures in the examined countries. This indicator denoting the extent of a government’s role has changed over time especially in relation to individual expenditure and society.

The graph shows Egypt having the lowest percentage which gradually decreased over time. The Egyptian government finances less than 30% of health expenditure and the rest mostly comes from the citizens’ spending money, putting individuals under pressure. When comparing KSA to Turkey, government expenditure on health represents more than 60% of total health expenditures in both countries, with notable improvement in Turkey reaching up to 78%. In both countries, healthcare expenses are supported by their respective governments with Turkey notably higher in percentage than KSA. 

Overall, individuals in Egypt received the least government health expenditure, though the amount increased slightly over time. Economic development in KSA puts individuals in a better position as they receive more government expenditure for healthcare. However, the Turkish government showed more resilience against fluctuations in government healthcare expenditures.

Furthermore, KSA has more experience than Turkey and Egypt. KSA witnessed the outbreak of Middle East Respiratory Syndrome (MERS) in September 2012. Most of the cases were diagnosed in KSA and South Korea, and were more aggressive in nature with a fatality rate of around 34.%.9 Having this experience gave KSA more knowledge and skills in order to treat similar crises. Similar to China, analysts claimed that the political climate in KSA negatively affected how it dealt with the MERS crisis.

 KSA’s government ignored or rejected some international aid offers, obscured clinical data and its spread, and did not manage the crisis effectively as the number of cases greatly increased after the initial outbreak.10 This caused some to argue that the Minster of Health, Abdulla al-Rabia, was removed from office in 2014 because of new waves of the MERS outbreak.11 After al-Rabia’s removal, there were five different minsters over a span of 2 years, denoting a high rate of Minster of Health turn over before reaching the current mister who was appointed in 2016. 

The seriousness of the MERS disease initiated an internal debate in KSA regarding the best option for developing healthcare systems in the country to prepare for future expected similar outbreaks. Two options were discussed.12

The first was establishing a prevention and control centre, like in the United States and Canada, as a tertiary advanced healthcare centre responsible for dealing with similar outbreaks. The second option was to develop primary healthcare and public healthcare and make them more integrated at all levels. 

This option was to place more focus on developing the primary health care centres and place them as the cornerstone of health systems. On all levels, this experience was a good opportunity for KSA to increase its state capacity in dealing with similar outbreaks in the future. However, state capacity is not only limited to previous experience. 

The increasing rate of government healthcare expenditure is not a good sign in itself if it is not associated with an increasing state capacity in the healthcare sector. According to the World Bank Data, hospital beds per 1000 persons increased in Turkey and KSA and decreased in Egypt between 2000 and 2014. 

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The World Bank Data also shows that in 2018, the number of physicians per 1000 persons in Egypt was 0.4, 2.6 in KSA, and 1.8 in Turkey. For nurses and midwives, the percent was 1.8 in Egypt, 2.7 in Turkey, and 5.4 in KSA. 

The number of ventilators available in the ICU is another indicator of the development of state capacity. In KSA, the total number of ventilators was more than 8,000 according to the Minster of Public Health’s spokesman,14 which equals to 23.5 ventilators per 100,000 persons. The total number in Egypt was around 13,000,15 which equals to 13 ventilators per 100,000 persons. Turkey had an advantage over both countries in its numbers and ability to manufacture ventilators locally. 

By the end of April 2020, Turkey had 100 ventilators and this number is expected to reach 5,000 soon.16 This is another indicator of the Turkish state’s increasing capacity during this crisis.

During the Crisis: How did the Government Intervene?

Once the coronavirus crisis started, each government began to take some measures to tackle the crisis. Some of those measures were medical and others non-medical, but the goal was to prevent the spread of the disease, minimizing its side effects on the economy. 

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Table 2: Number of cases, deaths, and tests for Egypt, KSA, and Turkey. World Meter June 

  1. Government Medical Intervention 

The number of coronavirus tests per one million persons in each country can give us an estimation of the extent of government intervention in delivery of healthcare services. However, two factors need be mentioned. 

First, there is a difference between doing the test as part of the diagnosis process and as part of prevention and control measures. Massive testing for non-symptomatic patients as a measure of prevention and control has proven to be a good strategy that helped Germany and South Korea to deal with the crisis effectively.17

Second, in most world countries, only persons who tested positive for coronavirus are reported as a “positive case” in government records. This means that by increasing the number of coronavirus tests, governments will be able to come close to the real number of all infected cases in the society and to prevent the spread of the virus to the non-infected as well. In other words, doing more tests is important for prevention and awareness of the real number of cases present in the society.

In this regard, KSA comes first in the number of tests done per million persons, followed by Turkey and then Egypt coming in third with a notable gap. Also, there is high suspicion regarding the official data announced by the Egyptian government. Skepticism over a government’s numbers is a phenomenon that is not only exclusive to Egypt. In Turkey, the Medical Association attacked the Minister of Health for not following the WHO protocol for coronavirus diagnosis. According to them, the current numbers in Turkey do not represent the true numbers in reality.

18 Similar debates could be found in many other countries,19 but they are more prominent in Egypt. Since there is a low rate of coronavirus tests administered, the real number of cases is obscured as well as the real number of deaths. Moreover, there is an environment characterized by lack of transparency and misinformation that may be used for other motives.20

  1. Government Non-Medical Intervention 

Apart from healthcare policies, the governments usually follow many regulatory and preventive measures to contain the pandemic. In Turkey, the government suspended movements among cities, set a curfew for citizens above 65 and below 20 years of age, imposed a full curfew during weekends, and closed schools and universities in addition to many official offices. However, during weekdays many of the economic activities are still in progress in order to keep the economy working during this crisis.

 Putting it in a different way, the government classified the society into classes and directed protective measures for the most vulnerable classes, and at the same time it allowed the working class to work during weekdays.

 In contrast to “Herd Immunity”, Turkey has used the “Class Immunity” strategy which aims to limit the spread of the disease among the most vulnerable while enabling the economy to continue to function at the same time.21 This strategy consequently leads to the spread of infection among the working class, but, on the other hand, it protects vulnerable people and allows the economy to keep working. 

KSA seems to have prioritized health over economy thanks to its rentier nature. Therefore, implementing a more extensive curfew including all weekdays was not a difficult decision for the KSA government. This could be a good strategy in the short term, but it is not sustainable in the long term, taking into consideration the collapse in oil prices. 

The fall in oil price also affected KSA’s Vision 2020. This means that KSA is facing a twin crisis: the coronavirus crisis and oil price decline.22 Also, in the medium and long term, high infection rate among foreigners may have a negative impact on the working force capacity in KSA. 

Unique to the measures taken by KSA were the closure of the holy mosques in Makkah and Medina and the cancellation of Umrah during Ramadan. This was followed by the decision to temporarily suspend Hajj in 2020 to international visitors. 

In Egypt, the government imposed a night curfew, closed schools, universities, and other public institutions, and imposed full curfew in massive infected areas as a preventive measure.

In the beginning, the government appeared to be striving to balance between keeping the economy functioning and protecting citizens’ health. However, as time passed, protecting the Egyptian economy emerged as a more crucial priority for the government as it started to ease its measures and place a strategy based on citizens self-imposing social distancing with less imposed measures from the government. In other words, the governments started establishing a more individual-centered approach. 

Another remark concerning crisis management in Egypt is the rising role of civilians in the government, especially the Prime Minster and Minster of Health, at the expense of the well-established military roles in policy and decision making. This was an unexpected step inviting analysis.23 Until now, it appears that the military is more focused on protecting its personnel from infection after few of the high ranked officers contracted the virus and passed away. 

Now, with the easing of measures in many countries, the Lockdown Rollback Checklist is a valid framework to measure the level of readiness for re-opening. The World Health Organization (WHO) recommends using the Lockdown Rollback Checklist, despite the fact that it only takes into consideration four of the WHO required measures. 

According to this checklist, both Turkey and KSA are more prepared to ease out the lockdown than Egypt. Egypt has a notable shortcoming in testing and in community understanding making the situation less favorable for re-opening. 

Table 3: Lockdown Rollback Checklist 1 June 2020 24

  1. Improving State Capacity 

In this crisis, testing capacity has gained public attention for evaluating government responses. In testing capacity, Turkey comes first by increasing its capacity from around 11,000 tests per day in late March to more than 40,000 per day. More importantly, Turkey now has the ability to produce the test locally and it has started exporting test kits to 50 countries.

In Egypt, at the end of March, WHO announced that with its support, Egypt can administer 200,000 tests for coronavirus.26 It is not yet clear how the government is going to increase its capacity in testing, especially with the rising number of new patients. 

KSA announced that the state has no problem with its capacity to administer the coronavirus tests, and this is evident in the ratio of number of tests for every million persons. However, KSA does not have yet the ability to manufacture the test locally. 

In addition to testing capacity, another indicator is hospital capacity. Turkey has accelerated finishing two major hospitals in Istanbul, one was set to be finished at the end of April and the other at the end of May.27 Furthermore, it opened other emergency hospitals. The government accelerated opening those hospitals because of coronavirus to add more capacity to Turkish healthcare systems. 

Both KSA and Egypt have temporally opened hospitals for coronavirus and increased their bed capacity, in contrast to Turkey where the new spaces and services provided during the pandemic are of a permanent nature. 

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Which Country Performed Better?

There is a debate regarding how to measure the impact of coronavirus on the population’s health. Evidently, the number of total cases and the number of deaths per million are important indicators. However, they are not accurate as they depend on the number of coronavirus tests done which varies from one country to another. 

For example, Egypt has the highest number of deaths per million followed by KSA coming in second and Turkey last. Yet, this could be misleading. Egypt stands last in the number and percentage of coronavirus tests performed inferring that it has the largest unrecorded coronavirus causalities. 

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Table 4: Fatality rate in Egypt, KSA, and Turkey.

Source: Statista. “Coronavirus Death Rate by Country,” 2020. Accessed June 30, 2020 

The third indicator used for measuring health outcomes is fatality rate. The indicator calculates the number of recorded deaths from among the recorded infected cases indicating the efficiency of the healthcare system in dealing with the recorded infected cases. In this indicator, Egypt has the highest percentage of fatalities. According to official numbers, this may seem unexpected.

Egypt has the lowest rate of an infected population and consequently one would expect Egypt to have a better fatality rate. However, the ineffectiveness of the Egyptian healthcare system accompanied by insufficient testing could explain the result.

The significance of a fatality rate is due to the association with the official number of recorded coronavirus cases. In other words, it is an indicator of the performance of healthcare systems. According to the current date, this should be an alarming sign of the ability of the Egyptian healthcare system to deal with the future developments of the coronavirus crisis in Egypt. 

KSA has the lowest fatality rate among the examined countries and it is among the lowest in the world. This indicates the effectiveness of its healthcare system. Yet, another significant factor could explain the adept performance exhibited in KSA: the age structure of its population and more specifically the infected persons. 

A recent policy brief suggests that the role of age be considered when examining the coronavirus spread.28 The three examined countries have a middle-aged population, with the median age ranging between 24 years old in Egypt, 27 in KSA, and 31 in Turkey. So, how has KSA been able to achieve this adept record in fatality rate? 

Two reasons could explain this phenomenon. The first factor to consider is the percent of citizens above 65 years of age. According to the World Bank Data, those above 65 years old are 5% in Egypt, 3% in KSA, and 8% in Turkey.

The second factor is that the majority of cases are among the middle-aged foreign workers (75% according to official numbers). In other words, the age of those infected in KSA is a helpful factor in achieving an adept outcome. 

On the other side, Turkey has the highest median age structure and the highest percentage of citizens above 65 years of age which forces it to deal with more challenges during the crisis. This is elucidated by the official Turkish statement that 93% of deaths in May were people above 65 years of age denoting that that age group has been most affected by crisis.

Coronavirus management is not only limited to the healthcare sector. The above analysis was concerned with the healthcare management of the crisis. However, its economic and political implications are still significant, and they may affect the healthcare management in the future. In this regard, the nature of the political economy plays a role in shaping crisis management.

Looking forward: which governments will be able to act strategically? 

The coronavirus pandemic will not end within weeks. Countries that perceive the coronavirus crisis as an extended war have a better chance of overcoming it. During that time, it is more significant to be building state capacity for the current and future challenges while trying to win the current battles. At this point, two remarks have emerged.

First, a country’s ability to win its first battle against coronavirus is crucial in determining its final outcomes. The crisis was sudden and unprecedented in most countries, yet some countries have been more efficient in dealing with the crisis than others. Up until the present time, KSA and Turkey show signs of success in their healthcare crisis management in terms of fatality rate and healthcare state capacity.

Second, while government performance is important in the short-term, its ability to increase its state capacity on the long-term is more significant. The more governments are prepared for the future, the more likely they are able to tackle this problem effectively. The situation looks promising for KSA that has a previous experience dealing with a similar crisis because of the MERS outbreak in 2014 and was prepared for the current crisis.

 The fatality rate is very low, and the government has sufficient capacity to deal with the crisis. However, a new wave of the disease may put the government under pressure. The spread of infection among foreign workers is an advantage for the KSA government until now as it lowers its fatality rate.31 However, if the crisis intensifies among foreign workers, this would pose a threat for several reasons.

First, many of those workers do not have medical insurance and need government assistance in obtaining good healthcare. Taking into consideration the drop in oil price and the downsizing in government spending, this could be an additional financial load on the government.

Second, a huge outbreak among foreign workers will affect the work force in KSA causing many sectors to not work properly. Shortage in the foreign workforce will add another load onto the government at the economic level. 

Lastly, an uncontrolled outbreak among foreign workers would bring problems from government workers and affect the international picture of the KSA government. 

In terms of Turkey, from a healthcare perspective, it has managed the coronavirus crisis effectively and increased its state capacity significantly. However, this may be considered in a small achievement in the much larger framework. Turkey’s challenge right now is not in the healthcare system but rather in its economy.

32 Considering the non-rentier nature of the Turkish economy, Turkey needs to keep its economy working while keeping the infection rate and fatality rate at a minimum. For example, the coronavirus crisis affected the tourism sector and the Turkish lira has met recent challenges. Keeping the economy working while maintaining good healthcare management is a true challenge for the government. 

In Egypt, the coronavirus crisis revealed weaknesses in its healthcare system. The high rate of fatality and insufficient state capacity puts Egypt under pressure. What makes the case even worse is the low rate of testing that causes inaccurate official numbers and suggests a significant difference between the real numbers and the public ones. 

What is apparent in the three countries is the nature and extent of the economic development and each state’s healthcare capacity that have shaped the way each government has responded to the coronavirus crisis, in addition to the previous experience of KSA with the MERS outbreak. 

The political implications of the coronavirus crisis makes coronavirus management pivotal in the MENA region. In Turkey, where elections are of essence, the coronavirus crisis acts as a double-edged sword. On the one side, the government fears early elections with the current political polarization especially after the AKP party lost two major cities (Istanbul and Ankara) in the last local elections in 2019.

 Many emerging opposing actors and parties are preparing themselves for the next elections. An early election amidst a severe economic crisis with signs of government incompetence in crisis management will be a real challenge. On the other side, managing the coronavirus successfully will add more credit to the government and AK party and improve their position in local politics. 

In authoritarian regimes, the rise of popular uprisings is a real challenge for the governments. In KSA, the government still has sufficient financial resources to provide public services. However, the depreciation in oil demand and prices will challenge the strategy’s sustainability on the long run. Egypt, on the contrary, does not have the same resources as KSA.

 Failure of managing the economic and health sectors of the coronavirus crisis may lead to social unrest. So far, the situation is under control. However, taking into consideration the current capacity of Egyptian healthcare and economic difficulties, the Egyptian government needs more than just luck to keep the situation under control.

Lastly, if a second wave of the pandemic hits those countries, what will the result be? In the case of Egypt, its healthcare system will meet severe challenges and it is difficult to predict whether it will be able to manage it. These healthcare management challenges will be accompanied by a severe economic crisis, a situation unfavorable for any government. 

KSA will not face true challenges in the healthcare system. If the crisis continues for months, there may be some challenges for its capacity to continue with the same high standards. The true challenge in KSA would happen if the oil prices declined again and the world economy entered a severe recession. The rentier nature of the KSA economy makes it dependent on oil price. The decrease in oil price for months is a true problem for KSA at both the economic and healthcare level. 

For Turkey, the improved state capacity in the healthcare system would place Turkey in a better position for dealing with future waves. Turkey could use its domestic products and services to provide the necessary medical supplies. However, the nature of its economy, global recession, a stagnant tourism sector, and mismanagement of the foreign currency exchange pose true challenges for Turkey. In other words, Turkey will most likely be able to manage the healthcare aspect smoothly, but it will face more challenges in economic management. 

No one hopes for more coronavirus waves, but those who are well-prepared for future crises will be able to manage it successfully.