How Egypt's investment in health care is improving access and outcomes

The introduction of an overarching health care reform in 2018, aimed at providing universal coverage, has helped to initiate a complete overhaul of the Egyptian public health system. The Universal Health Insurance (UHI) policy is seeking to reshape the fragmented health care system and encourage greater collaboration between the public and private sectors. Currently, rapid population growth and securing funding for health care remain the two largest considerations for sector development.

With medical staff-to-patient ratios and hospital bed numbers below the regional average, the country is particularly focused on capacity expansion in the health care sector. The additional burden placed on already strained hospitals by the Covid-19 pandemic has underscored the need for greater funding. At the same time, the pandemic has helped to spur investment across the sector, especially in telehealth and medical technologies, aiding the progress of the UHI.

Structure & Oversight

The Ministry of Health and Population (MoHP) is the principal provider of primary, preventive and curative health care in Egypt. It oversees the country’s primary health care centres, as well as general hospitals, district hospitals, and integrated and specialised hospitals. The MoHP also manages the implementation of national health legislation, which includes the UHI policy.

The population of Egypt is expected to grow by 1.9% per year to reach just under 160m by 2050, underscoring the scope of infrastructure and staffing that will be needed to achieve universal care. By the end of the decade Egypt will require approximately 38,000 new beds at an estimated cost of $8bn-13bn, based on its current bed-to-patient ratio. Additionally, a further 88,000 doctors, 73,000 nurses and 18,000 pharmacists are expected to be needed in order to meet increased public demand.

Despite ambitious public health care plans, government spending on health remains below the MENA average. In 2019 health care spending in Egypt stood at 4.7% of GDP, compared to the MENA average of 5.5%. Government spending on health in FY 2021/22 was expected to be 16.3% higher than in FY 2020/21, at LE108.8bn ($6.9bn), compared to LE93.5bn ($5.9bn). Private health expenditure made up roughly 71% of all health care spending in Egypt in 2019 and per capita spending equated to $150.

General Indicators

Life expectancy has increased over the last two decades, from 68.3 years in 1999 to 72 in 2020. Egypt has an ageing population, with residents older than 65 representing 5.3% of the population in 2020, compared to 4.9% in 2000. In the future, one of the main areas of demand in the health system will be geriatric care, as the number of residents aged over 65 is set to move from an estimated 4.3m in 2021 to 12.3m in 2030, according to the 2021 “Egypt Healthcare Overview” report by Colliers. Therefore, more beds will be required for long-term care, and there will be heightened demand for services ranging from rehabilitation to home care.

Meanwhile, the birth rate is decreasing, falling from 33.2 per 1000 people in 1990 to 25.7 in 2019. At the same time, the rate of births attended by skilled staff increased substantially, from 60.9% in 2000 to 91.5% in 2014. The maternal mortality rate has fallen, from 47 per 100,000 in 2007 to 37 in 2017, alongside the infant mortality rate, which decreased from 24 per 1000 live births in 2010 to 16.6 in 2020.

Non-communicable Diseases

The number of people suffering from non-communicable diseases (NCDs) has steadily increased in recent years, mainly due to lifestyle factors associated with the higher disposable income of a growing middle class. According to the World Health Organisation (WHO), Egypt is 18th in the world in terms of obesity, with 32% of Egyptian adults categorised as obese.

Other lifestyle factors are also contributing to the prevalence of NCDs in Egypt. A 2017 MoHP and WHO survey showed that 43.4% of males and 0.5% of females were smokers, and that 24.9% of the population was physically inactive.

The percentage of deaths caused by NCDs has increased from 81.9% in 2010 to 85.6% in 2019, making it the leading cause of death in Egypt. At the same time, the prevalence of diabetes has risen around the world in recent years. In the MENA region, there are approximately 55m people with diabetes, a figure that is expected to grow to 108m by 2045. In Egypt, as much as 17.2% of the population aged 20-79 years had diabetes as of 2019, totalling around 11.9m people, according to the International Diabetes Foundation. In addition, approximately 26% of Egyptian adults meet the criteria for hypertension, but a concrete prevalence rate is unknown.

In 2018 the MoHP worked with the WHO to establish a four-year Multisectoral Action Plan for Non-communicable Diseases Prevention and Control. Informed by this document, the MoHP established the comprehensive NCD Action Plan 2018-22, in line with the Global Action Plan for the Prevention and Control of NCDs 2013-20 and the UN Sustainable Development Goals (SDGs). As part of the digital transformation, and in line with the Egypt Vision 2030 strategy, the MoHP announced the creation of a database to list all patients in Egypt that suffer from diabetes as a means of better tracking the disease.

Communicable Diseases

Death from communicable diseases, as well as from maternal, prenatal and nutrition conditions, by contrast, fell over the last decade, from 12.8% of the total in 2010 to 9.6% in 2019. Egypt has made progress in managing multiple diseases. For example, the government’s 100 Million Healthy Lives initiative, running from 2018 to 2023, focuses on the prevention and early detection of several diseases. One of the main goals of the programme is to lower the incidence of Hepatitis C, with Egypt planning to become the first country to eradicate the disease. In the first year of the programme, nearly 50m people underwent screening and 1m were treated for infection. Egypt used to have one of the highest rates of Hepatitis C in the world; indeed, 11.9% of the population was estimated to have antibodies in 2018.

The rate of HIV, meanwhile, has remained low in recent years, and stood at 0.05% of the population in 2019. This may partly be due to improved sexual health education in recent years, although the use of contraception varies. Between 2008 and 2014 the overall level of contraception use dropped slightly, from 60% to 58%, but the proportion of contraceptive pill users increased from 12% to 16%. In 2017 the government introduced a family planning education programme, aimed primarily at rural communities. Rural populations tend to avoid contraception due to cultural and religious norms.

The MoHP operates approximately 6000 family planning clinics across the country, which offer free services and subsidised contraceptives. As part of the programme, the MoHP planned to send 12,000 family planning professionals to 18 rural provinces to enhance education around reproductive health.

Public Health Care

The UHI policy, launched by the government in 2018, is aimed at reforming the highly fragmented health system. While universal health care has been a government aim since the 1960s, the UHI marks the first comprehensive reform introduced to accomplish the task. The scheme is expected to reach all governorates by 2027, with implementation taking place over six phases based on geographic area. By the end of 2021, 5m patients were registered under the UHI scheme in the firstphase governorates of Port Said, Luxor, Ismailia, Aswan, Suez and South Sinai. The second phase, taking place between 2021 and 2023, will expand coverage to Matrouh, the Red Sea and Qena.

The UHI scheme is expected to cost some LE210bn ($13.3bn) annually, which will be paid through a combination of employee, employer and public contributions. The government also plans to offer assistance for those who cannot afford to pay contributions to enrol in the system, in order to ensure truly universal coverage. In practice, however, informal workers may face challenges in providing the necessary documentation to be considered exempt, despite not meeting the earnings threshold.

The government has made strides in its health care provision, with 95% of the population living within 5 km of a health care facility. This has been made possible in part by the large number of private health facilities across the country. Egypt currently has 1782 hospitals, 1130 of which are private, with a total of 128,344 hospital beds. With 1.3 beds per 1000 people, Egypt remains below the MENA region average of 1.5 beds per 1000.

Some of the persistent challenges to the public health system include medical staff shortages and brain drain; scarcity of hospital beds; and overstretched and insufficiently equipped facilities. Egypt has less than 1 physician per 1000 people, although this is rising: in 2019 there were 0.7 physicians per 1000 people, compared to 0.5 in 2003. In 2018 there were 1.9 nurses and midwives per 1000 people, less than the MENA average of 2.5 per 1000. Egyptian medical graduates are often drawn to working at hospitals abroad due to the higher wages and more attractive working conditions on offer. In 2021 the minister of health and population, Dr Hala Zayed, stated that 67% of Egyptian doctors were working overseas. According to the Egyptian Centre for Economic Studies, 7000 doctors emigrated during the Covid-19 pandemic alone.

The pandemic placed an increased burden on public hospitals, requiring higher levels of spending to meet the demand of the influx of patients, as well as the need to acquire specialised medical equipment and personal protective equipment.

As of end-April 2022 Egypt had reported over 515,000 Covid-19 cases and 24,000 Covid-19 deaths. Throughout the pandemic, Egypt received high levels of international support, including funding for Covid-19-related health care – $5.2bn from the IMF and $50m from the World Bank in 2020 – and vaccines through the WHO’s COVAX scheme. As of mid-June 2022, 35% of the population was fully vaccinated and 13% was partially vaccinated.

There were several other successes seen in its response to the Covid-19 pandemic, including the preparedness of teaching hospitals, which maintained an inpatient bed occupancy rate of 70% or less and ventilator utilisation for fewer than 40% of confirmed cases. The government responded quickly to the health crisis by closing schools, universities and businesses, and shutting travel routes. Among other measures, it allocated LE8bn ($508.3m) for the purchase of urgent medical supplies and for medical staff wages, and provided around LE3bn ($190.6m) in cash subsidies to other affected workers.

Private Health Care

Private sector hospitals account for 63% of all of hospitals in the country, but the segment is highly fragmented: it has an average of 31 beds per building, compared to 96 beds in government hospitals and 209 in parastatal hospitals. The number of private health institutions has been steadily increasing in recent years as the public perception of public health care facilities has deteriorated. The insufficient number of hospital beds and medical staff to meet the demands of the growing population have driven many Egyptians to opt for private alternatives.

The high uptake of private health care services means that Egypt’s out-of-pocket spending equalled 62.7% of total health care expenditure in 2019, compared to the global average of 18.1% and the MENA region average of 28.8% that year. This equates to around $94 in out-of-pocket spending on health care per capita. The government expects that UHI will help to lower out-of-pocket spending over the next decade, and provide health care to the estimated 30% of the population who cannot afford it.

The national UHI policy presents a significant opportunity for already well-established private health care providers. Incorporating private health services into the system could save the government from having to purchase new equipment and provide specialist training across public hospitals, investing instead in existing facilities and knowledge.

A similar public-private partnership (PPP) strategy has been followed in several other countries, including Brazil, Colombia, Georgia, South Africa and the UK. However, Egypt would likely need to introduce several policy changes in order for this system to be successful, including amending regulations on contracts for services, expanding the capacity of medical facilities and staff, and introducing incentives to improve efficiency.

In response to the pandemic, there has been greater interest in advancing telehealth and medical technologies through increased investment in health care start-ups. There are roughly 100 health care start-ups in Egypt, many of which became more prominent in 2020 and 2021. Rural populations have benefitted from the rapid expansion of telehealth and remote medical services since 2020. While greater disparities between urban and rural settings became more apparent during the pandemic, initiatives such as these have helped bridge the gap.

The MoHP has welcomed platforms such as Vezeeta and Yodawy to support medical service delivery. This has demonstrated the potential for growth in the private sector, as well as opportunities to accelerate the digital transformation across the health sector. With the global digital health care market expected to reach a value of $235bn by 2030, particularly in the areas of machine learning and artificial intelligence (AI), Egypt has the potential to develop its digital health care significantly. Egypt hopes to derive 7.7% of its GDP through AI by the end of the decade and, as the sixth pillar of the Egypt Vision 2030 strategy, health care will be at the centre of the country’s digitalisation plan.

Medical Research

On a global scale, Egypt emerged as a centre for medical research in 2020. Having developed several partnerships with countries across Western Europe and North America, Egypt has increased the number of health-related articles published each year. In 2020 researchers in the country published more than 4100 papers on general medicine, 946 pharmaceutical sciences articles, 914 drug discovery papers, 911 on surgery, 589 on biomedical engineering and 500 on oncology, according to the Institute for Scientific Information.

Zayed announced in 2021 that Egypt was planning to establish a national institute for health and medical research in collaboration with Harvard University. The institute is expected to be situated in the New Administrative Capital, east of Cairo. It aims to offer training opportunities for medical staff through its centres for general health and clinical research. This would expand upon the existing Medical Research Institute at Alexandria University.

Pharmaceutical Manufacturing

The government is working to establish Egypt as a regional base for pharmaceutical manufacturing. In April 2021 President Abdel Fattah El Sisi inaugurated the largest pharmaceutical manufacturing centre in the MENA region in the Greater Cairo area. It plans to produce some 150m packs of 150 different types of medication each year. The government hopes that establishing Egypt as a pharmaceutical centre will encourage partnerships between the public and private sectors, attract multinational drug makers and encourage drug price control.

Egypt has seen substantial growth in its pharmaceutical market, with the total revenue from prescription drugs and over-the-counter medicines expected to reach some LE103.7bn ($6.6bn) by 2025 and LE157.9bn ($10bn) by 2030. In this vein, the MoHP established a new pharmaceutical regulator in 2019 to improve standards. The Egyptian Drug Authority (EDA) aims to reduce counterfeit drug sales, manage new product registrations, and oversee import and export markets.

Beyond traditional pharmaceuticals, Egypt has played a leading role in the production of Covid-19 vaccines. In the summer of 2021 Zayed inaugurated the Egyptian Holding Company for Biological Products and Vaccines (VACSERA) factory complex, to produce the VACSERA-Sinovac vaccine using materials from China. This vaccine received emergency licensing from the EDA for manufacturing, domestic use and export. According to the WHO, Egypt is one of six African countries that have been given the technology required to produce mRNA vaccines. By February 2022 Egypt had produced more than 30m VACSERA-Sinovac vaccines.

However, several elements are likely to shape investment trends in the pharmaceutical industry in the coming years. For example, relatively weak intellectual property laws and government pricing policies make the branded drugs market less attractive to investors. As a result, generic drugs are expected to grow significantly compared to patented drugs. At present, generic drugs make up some 36% of all medicine sales and are expected to reach 41% by 2025, according to a June 2021 report by Fitch Solutions. Patented drug sales are projected to decrease from 48% to 41% in the same timeframe.

Outlook

Having completed phase one of the UHI scheme, Egypt has advanced in its aim to deliver universal public health care to its entire population. While Covid-19 has created challenges, particularly concerning funding and staff shortages, the pandemic has also helped accelerate the UHI scheme and encouraged greater investment in telemedicine. However, with medical staff and hospital bed numbers below the regional average, increasing health care expenditure and investment will be key to achieving the ambitious sector goals set out in the Egypt Vision 2030 strategy, in line with the UN SDGs.