When economies collapse, hospitals often collapse with them. That is the stark conclusion of a new systematic review examining how countries in West Asia and North Africa financed their health systems through nearly two decades of turbulence, from the global financial crisis of 2008 through the shocks of 2026. The research, published in BMC Health Services Research by a team at Shiraz University of Medical Sciences in Iran, sifted through thousands of records to identify just 27 studies that met rigorous inclusion criteria, and what those studies reveal is a region where sanctions, currency devaluations, and austerity programs have repeatedly pushed health financing structures to the breaking point. The review is among the first to systematically map macro-level health financing policy responses across the WANA region, a geographic band stretching from Morocco to Iran that has endured some of the most severe macroeconomic instability of the twenty-first century.
The methodological architecture of the review is itself instructive. The researchers searched six major electronic databases, including PubMed, Scopus, Web of Science, Embase, EconLit, and PAIS, along with four sources of grey literature, capturing material published up to April 29, 2026. From an initial pool of 3,455 records, the screening process distilled the evidence down to 27 studies. Each was appraised for methodological quality using tools matched to its design: the Joanna Briggs Institute checklist, the Mixed Methods Appraisal Tool, and the AACODS checklist designed for grey literature, which evaluates authority, accuracy, coverage, objectivity, date, and significance. The search strategy itself was peer-reviewed against the PRESS standard, and the review was registered prospectively, in line with PRISMA 2020 reporting guidelines. Twenty-three of the included studies were judged to be of high quality and four of moderate quality, a distribution that lends considerable weight to the synthesis that follows.
The analytical framework at the heart of the paper is the so-called ‘abc’ structural model, which dissects health financing institutions into three interacting layers: policy goals, institutional tasks, and organizational positions. By measuring the degree of alignment among these layers, the authors could quantify what they call structural misalignment, expressed as a delta-E value greater than zero. The headline finding is sobering: 89 percent of the included studies, 24 of 27, documented such misalignment, and the pattern held regardless of study quality rating. In practical terms, this means that in nearly every crisis examined, the goals that governments articulated for their health systems were not matched by the institutional tasks those systems were actually equipped to perform, and those tasks in turn were not supported by the organizational mandates and resources assigned to them. The result is a chronic gap between what health financing systems promise and what they can deliver under fiscal stress.
The review identifies distinct shock profiles with distinct consequences. International sanctions, for example, predominantly disrupted pharmaceutical supply chains, choking off access to essential medicines through banking restrictions, import controls, and the withdrawal of international suppliers unwilling to navigate compliance risk. Currency collapses operated through a different channel, eroding the revenue base of the health sector itself. When a national currency loses most of its value, government budgets denominated in that currency can no longer purchase imported drugs, equipment, and vaccines priced in hard currency, while salaried health workers see the real value of their wages evaporate. These two mechanisms, supply-side strangulation and revenue erosion, recur across the region’s crisis episodes and interact in ways that compound each other, leaving health systems simultaneously poorer and less able to convert whatever resources remain into effective services.
Perhaps the most consequential finding concerns risk pooling, the mechanism by which health financing systems spread financial risk across populations instead of leaving individuals to bear the full cost of illness. In Lebanon and Jordan, the review found that fragmented risk pooling, in which multiple small, poorly coordinated insurance schemes cover separate slices of the population, exacerbated what the authors describe as health poverty during crises. Fragmentation matters because small pools lack the reserves and bargaining power to absorb shocks. When an economic crisis hits, households covered by weak or fragmented schemes are forced back onto out-of-pocket payments, and out-of-pocket spending is the financing mechanism most strongly associated with catastrophic health expenditure, the technical term for medical costs so high they push households into destitution or force them to forgo care entirely. The WANA evidence suggests that the architecture of pooling, not merely the level of funding, determines whether a health system bends or breaks under macroeconomic pressure.
What, then, can be done? The authors argue that two structural reforms stand out. The first is redesigning institutional tasks, the M2 component of their structural model, so that the day-to-day functions of health financing bodies actually correspond to stated policy goals rather than drifting into misalignment. The second is establishing automatic counter-cyclical financing mechanisms, pre-legislated arrangements that channel additional resources into health when the economy contracts, without requiring ad hoc political decisions in the middle of a crisis. The logic is analogous to automatic stabilizers in fiscal policy: because crises arrive suddenly and political attention is scarce precisely when need is greatest, the protective response should be built into the system in advance. Without such mechanisms, health budgets in the region have tended to be cut procyclically, falling exactly when demand for publicly financed care rises.
The regional focus of the review deserves emphasis. WANA countries occupy an uncomfortable position in global health economics: many are middle-income states with sophisticated health infrastructure but acute exposure to geopolitical and macroeconomic volatility. Sanctions regimes, oil price swings, conflict, refugee flows, and currency instability have produced repeated fiscal shocks over the review’s 2008 to 2026 window. The authors frame the stakes in systemic terms, warning that policymakers must align macro-fiscal mandates with health sector positions to prevent systemic collapse during economic shocks. That phrasing reflects a growing recognition in the health policy literature that health system resilience is not simply a matter of clinical capacity or emergency preparedness, but of the financial plumbing that determines whether money reaches services when the broader economy is in free fall.
The review also contributes to a methodological conversation about how such evidence is produced. The authors disclose that a large language model was used during manuscript preparation for language editing and for optimizing the syntax of the systematic review search strategy, with all AI-generated suggestions critically reviewed and verified by the human authors, who retain full responsibility for the content. No AI tool was used to generate original research data, analysis, or scientific conclusions. The research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector, and the authors declare no competing interests. The study protocol was reviewed by the Ethics Committee of Shiraz University of Medical Sciences, and because the work synthesizes publicly available secondary data, formal ethical approval for primary human research was not required.
For the wider field, the implications extend well beyond the region studied. Low- and middle-income countries everywhere face the twin pressures of constrained fiscal space and rising health needs, and the WANA experience functions as a stress test of health financing theory under extreme conditions. The finding that structural misalignment is nearly universal in crisis settings suggests that incremental budget adjustments are insufficient; what is required is institutional redesign that hard-wires financial protection into the architecture of the system. The review’s call for automatic counter-cyclical mechanisms echoes a broader movement toward resilience-oriented health financing, in which the goal is not merely efficiency in calm times but survivability in stormy ones. As economic volatility becomes a defining feature of the global landscape, the lessons distilled from these 27 studies offer a warning and a template in equal measure: health systems that fail to align their goals, tasks, and organizational mandates will pay for that misalignment in the currency of human health, and the poorest households will pay first.
Subject of Research: Health financing policy responses to economic crises in West Asian and North African countries
Article Title: Health financing policy responses to economic crises in WANA countries: a systematic review (2008–2026)
Article References: Kharazmi, E., Lotfi, F., Azizi, N., Ostovar, S., & Kharazmi, A. (2026). Health financing policy responses to economic crises in WANA countries: a systematic review (2008–2026). BMC Health Services Research. https://doi.org/10.1186/s12913-026-15743-0
Image Credits: AI Generated
DOI: 10.1186/s12913-026-15743-0
Keywords: health financing, economic crisis, health system resilience, West Asia and North Africa, financial protection, risk pooling, universal health coverage, sanctions, currency devaluation, catastrophic health expenditure, health policy, systematic review
News Source: Ophelia Keating. (October 5, 2026). Economic Crises Are Breaking Health Systems Across West Asia and North Africa, Review Finds. Scienmag.
