Ensuring equal access: Addressing the need for better service delivery, while pharmaceuticals posts strong results

By most accounts, Egypt has made remarkable progress in improving the health and welfare of its people over the past 30 years. The country’s disease profile resembles that of more developed countries. Immunisation rates, life expectancy and infant mortality have all improved markedly, with much of this progress being brought about by a concerted government-led effort. Yet, while the top-down model has proven effective in many regards, considerable work remains, particularly with respect to childhood nutrition, insurance coverage and preventative care.

In order to address these needs, Egypt will need to mobilise more economic resources and expertise from the private sector, without sacrificing its commitment to ensuring equitable care for all citizens. The challenge will be finding the right balance between old and new, public and private. Important responsibilities for the government remain, but the private sector has proven more effective at improving the quality of care and facilities. Seen in this light, perhaps the greatest contribution the government can make to the health sector will be to create and maintain a regulatory environment that encourages public-private partnerships.

COVERAGE: Beginning in 1964, access to primary health care has been a constitutionally guaranteed right of all Egyptian citizens. That same year, the government-run Health Insurance Organisation (HIO) was established to serve as both an insurer and a provider of care to all workers in the formal sector, students, pensioners, widowers and newborns. HIO currently covers 45% of Egyptians. Another 25% are covered by private or parastatal insurance. The remaining 30% (an estimated 25m people) are uninsured, and while they are eligible to receive free primary care, the vast majority do not access these services. The problem is not one of geography – nearly 95% of Egypt’s population resides within 5 km of a health facility. Instead, health care delivery has been limited by a number of factors, including the complexities of the country’s health insurance system, its highly overburdened public care facilities and an under-informed public.

INSURANCE STRUCTURE: The Ministry of Health and Population (MOHP) has pursued a pluralistic approach to insurance with customers choosing between different plans offered by the government, private companies and parastatal organisations.

Alongside HIO, over 80 private companies provide health insurance to a growing number of patients, and they have seen revenues soar. The private sector currently operates more than 2000 in-patient facilities with an estimated 24,000 beds – or 16% of Egypt’s total capacity. The government has promoted parastatal insurance as a way to extend coverage to the uninsured and foster greater cooperation between the public and private sectors. Under parastatal programmes, care at public health facilities would remain free of charge while the state would cover at least 75% of care provided at government-approved private facilities.

TRACK RECORD: Egyptian health officials deserve credit for significant accomplishments, including the eradication of diseases such as polio and the creation of national programmes for combating tuberculosis and viral hepatitis B and C. At the same time, infection rates for many diseases remain stubbornly high and the number of Egyptians suffering from lifestyle-related diseases is on the rise.

Several government-led health initiatives have met with real success. Infectious diseases now account for a minority of deaths. Egypt has been considered polio-free since 2006. According to the World Health Organisation (WHO), there have been no reported cases of diphtheria for more than a decade and neo-natal tetanus incidence rates are below 0.1 per 1000 live births. Under-five mortality rates have fallen sharply from 80.6 per 1000 live births in 1995 to 28.3 in 2008 – one of the steepest declines in the world. Over that same time frame, average life expectancy in Egypt jumped from 62.9 to 70.3 years. Credited for the improvements have been a robust immunisation effort, public awareness campaigns and improved standards of care.

MOVING FORWARD: Over the past three decades, Egypt’s health authorities have made a concerted effort to broaden care coverage and access. Beginning with the county’s first five-year plan, running during 1982-87, the government constructed a dozen new public hospitals and expanded the number of rural health facilities, adding some 10,000 beds in just five years. The number of beds continues to rise, topping 140,000 at present.

Population growth has also slowed considerably. According to the 2008 Egyptian Demographic and Health Survey (EDHS), total fertility has fallen 40%, from 5.3 children per woman in 1980 to just 3 in 2008. This decline reflects a global trend in developing countries, but government efforts deserve much of the credit. Of married women between 15 and 49 years old, more than 60% are now using some form of contraception, according to UNICEF.

LIFESTYLE CONCERNS: Egypt deserves praise for its immunisation record, but the prevalence of many non-communicable diseases, such as hypertension, type-II diabetes and heart disease is on the rise, due to a general lack of exercise, poor diet and high rates of smoking. According to the WHO, 23% of males and a staggering 46% of females in Egypt are obese. By the time an Egyptian turns 50, he or she has a 40% chance of suffering from hypertension.

The 2008 EDHS found that half of men between 20 and 50 years of age smoke cigarettes or water pipes on a daily basis, despite earlier legislation that raised cigarette prices by 10% and extended bans on smoking in public places to schools and government buildings. The number of women who smoke, however, is considerably lower.

Other hazards abound. Traffic accidents are another leading cause of death in Egypt, killing roughly 12,000 per year. That translates into a road traffic fatality rate of 42 per 100,000 population, according to the WHO, making Egypt’s roads some of the deadliest in the world. Air quality, particularly in Cairo and Alexandria, is a major contributor to respiratory illness. Lead has been removed from all petrol beginning in 1997, producing a 70% drop in lead particulates in the air over central Cairo. Nevertheless, factories around the capital continue to release tonnes of contaminants into the air each year, making Cairo’s air the second most polluted in the world after New Delhi, according to the WHO. Previously, the WHO had likened simply living in Cairo to smoking a pack of cigarettes a day.

INFECTIOUS DISEASES: Infection rates for hepatitis B and C remain alarmingly high. According to the National Committee for the Control of Viral Hepatitis, 10% of Egyptians are infected with hepatitis C virus (HCV). Medical researchers believe the real rate is 15-20% – the highest in the world.

A recent study has shown some progress. When infection rates are considered across five-year intervals, the highest rates are found in older men and women, but of men between 50 and 54 years of age who were tested for the HCV antibody in 2008, an alarming 49% tested positive.

A new method for diagnosing the disease could help bring death rates down through early detection. In early March 2012 the American University in Cairo (AUC) announced that a team of its researchers had developed an inexpensive and faster way of testing for hepatitis C. The new, one-hour test would replace a more expensive, two-step test spread over multiple days, significantly boosting the chances of early detection, which can raise the recovery rate to around 90%, according to Dr. Hassan Azzazy, the head of AUC’s research team.

Early detection is critical to treating many diseases, but most Egyptians cannot afford any kind of preventative testing that is not covered by their insurance. According to Al Borg Laboratories, an Egypt-based chain of medical laboratories, Egyptians average just 2.5 laboratory tests per year. This compares to an average of six per annum in Saudi Arabia, 16 in Europe and 22 in the US.

Dr. Vijayakumar Moses, the chief of the Young Child Survival and Development programme at UNICEF, credits the Egyptian government for sharp declines in rates of infection for communicable diseases and of infant mortality.

EDUCATION NEEDS: “Egypt has reached the Millennium Development Goal regarding child and infant mortality largely because the government has implemented very strong vertical programmes. This is a success story,” Moses told OBG. But there is still work to be done. “Infant mortality is significantly higher in Upper Egypt, where people are less exposed to the government’s public health programme.”

In cooperation with the MOHP, UNICEF conducted a study to identify the causes of this regional disparity. “We found that most infant death in Upper Egypt was taking place within one month of birth. The main problem was nutrition,” said Moses. New mothers were following customs handed down from earlier generations, feeding their newborns water and honey, rather than breast milk, for instance. “Without the important nutrients and antibodies contained in breast milk, the children were more susceptible to infection and disease.”

Moses also noted something of a paradox in the statistics on childhood health. “Egypt is unique in that infant mortality is quite low, yet malnutrition is rather high,” he told OBG. According to the 2008 Egyptian Demographic and Health Survey, approximately 25% of Egyptian children under the age of five suffer from chronic malnutrition, with rates slightly higher in rural areas. Acute malnutrition affects 7% of children under five years of age.

Improving on these figures requires making parents, particularly mothers, more aware of childhood nutrition, but efforts to do so are often hampered by illiteracy. Just two-thirds of Egyptians can read, with female literacy much lower. “Illiteracy is an enormous challenge,” Moses said. “It limits the amount of information people can absorb and requires consistent engagement on the part of the government.”

GOVERNANCE: While the nation has posted some impressive numbers in terms of childhood mortality and vaccination, its health care delivery could be better managed. At present, the overstaffed MOHP oversees health care with certain responsibilities belonging to the ministries of defence, interior, and higher education. HIO, various non-governmental organisations and some private practitioners are involved in managing, financing and providing health services, but oversight is wanting.

In fact, these shortcomings help explain the rise of the Muslim Brotherhood, which has spent years filling the gaps in Egypt’s public health care system. In addition to an expansive food distribution network, the Brotherhood has won support for offering free medical services to its poorer urban constituency.

EMERGENCY RESPONSE: The MOHP has received mixed grades in dealing with recent influenza outbreaks. In 2006 a UN expert on avian influenza praised the ministry for its quick response in instituting a programme of active surveillance of the virus. MOHP also instituted a large public education campaign. According to EDHS, 99% of Egyptians between 15 and 59 years of age were aware of avian influenza, with more than two-thirds of the population being aware of the symptoms. More importantly, there was little difference in this figure among groups with different educational backgrounds.

Nevertheless, Egypt remains at particular risk for avian influenza. One in three households maintain backyard flocks and one in five keep poultry or birds within living areas. Six years after first appearing in Egypt, the virus persists and the MOHP announced Egypt’s 58th fatality in March 2012.

Egyptian officials’ reaction to swine flu, on the other hand, was widely criticised. As concern over the virus spread in the spring of 2009, parliament voted to cull the country’s pigs – 300,000 of them – although the WHO had announced that the virus, despite its name, is not passed from pigs to humans.

HUMAN RESOURCES: The MOHP is focused on improved training for medical personnel. Between 6000 and 7000 students enrol in Egypt’s medical schools each year, considerably more than other MENA countries. And while the number of doctors and physicians is sufficient and graduates are well trained, support staff, such as nurses, is in short supply. There is a growing problem with specialisation, said Dr. Mounir Azmy Rizkallah, the head of general surgery at Ahmed Maher Teaching Hospital. “Most doctors used to go to Britain or France or Germany to focus on their specialties. But during the past 10 years, the requirements in Europe have become more restrictive and the number of positions available for non-European doctors has fallen. In addition, visas are more difficult to obtain, particularly after the terror attacks in Europe. All of this has hurt us,” he said.

Egypt is also hurt by brain drain and a stark urban-rural divide. Many physicians who are able to secure positions for specialisation abroad tend to stay, drawn by the higher pay and better working conditions. Of those who do return, most prefer settling in Cairo or Alexandria. “The most experienced and best-trained doctors live in cities. This is natural, but we need to improve the system,” said Rizkallah. “In particular, we need a more efficient way of referring rural patients to the cities for specialised care.”

PHARMACEUTICALS: Egypt’s burgeoning pharmaceuticals sector has posted strong growth figures in recent years and now accounts for more than a third of all health-related spending. Although down from growth rates of 15% or higher during previous years, the sector still grew at a robust 10.5% in 2011, despite political instability.

Helping the industry absorb the shock are several advantages, including a large domestic market, state-sponsored efforts to reduce endemic disease, and reforms designed to ease the registration process for new drugs. The MOHP expects the sector to continue growing at more than 10% each of the next three years. Such projections have multinational pharmaceutical firms expanding local operations and production. For instance, GlaxoSmithKlein (GSK) – already the largest pharmaceutical manufacturer in Egypt with a market share of 9% – has invested nearly $900m to expand local operations, while Novartis saw sales in Egypt exceed $250m in 2011, up nearly 20% year-on-year and nearly double the market average. Pfizer, which began operating in Egypt in 1962, saw its business up 11% in 2011.

There are, however, some hurdles to overcome. In an effort to make needed drugs affordable to a wider public, the government has installed price controls, but these are often so limited that prices fall below the cost of production. Counterfeiting and poor enforcement of patents are also problems in this highly fragmented market. Expired, counterfeit, or otherwise illegal drugs make up an estimated 10-15% of the local pharmaceuticals market.

Although hopes are high for a more stable macroeconomic environment, concerns remain. Speaking to OBG, Amre Mamdouh, chairman and managing director for GSK in Egypt, noted that the sector is susceptible because the currency depreciation has also been reducing companies’ profits. Government intervention to adjust the price may become necessary to keep players in the market.

OUTLOOK: The MOHP is keen to support the private sector, as a growing middle class in Egypt demands better facilities and services than are often available in public hospitals. Indeed, the private sector is now involved in every facet of health care delivery in Egypt, from managing private clinics to specialised hospitals, but these services remain out of reach for the majority of Egyptian citizens.

One unique model with promise can be seen at the Children’s Cancer Hospital Egypt (CCHE). Built and managed entirely on private donations, CCHE has grown into the largest paediatric cancer hospital in the world with 187 beds. (The second largest, St. Jude Children’s Research Hospital in Memphis, the US, has 73 beds). Like St. Jude’s, CHHE treats children with cancer free of charge regardless of their ability to pay; 90% of the hospital’s initial capital was raised in Egypt, with an average donation of less than $5. With a well-trained staff and quality equipment, the hospital’s cure rate is close to international standards, despite the unique challenges posed by infection control and post-surgical care in Egypt.

Within just five years, it has grown into a major centre for diagnosing and treating paediatric cancers, training doctors and educating the public. “We have become a model for the developing world,” Patricia Pruden, a registered-nurse-turned-strategic-planner for the hospital. “But we have set our sights much higher. We want to become the best paediatric cancer hospital in the world.”

Considering such models, the MOHP would like to ensure that every Egyptian has equal access to basic, high priority health services. Efforts to improve quality are now focusing on higher standards for care, facilities, diagnostics and the training of medical personnel. The government envisions an equitable system that provides services based on need and collects fees from individuals based on their ability to pay. In order to ensure the well-being of future generations, the ministry seeks a financially self-sufficient and sustainable model based on an efficient allocation of its human and infrastructure resources.