A rapidly rising population is placing strain on the system

The largest country in the Arab world, Egypt has wellestablished medical facilities. However, the health sector faces significant challenges in caring for a rapidly growing population using a system beset by structural weaknesses, against a backdrop of political upheaval and economic insecurity. With public funds limited, an increasing role for the private sector looks likely, creating new opportunities for international participation. However, Egypt’s political and economic situation means that progress on reform has been patchy.

The country is included in the Eastern Mediterranean region by the World Health Organisation (WHO). The group also includes Afghanistan, Iraq, Djibouti, Somalia, Syria, Pakistan and Iran, as well as Egypt’s North African neighbours and the wealthier states of the Gulf Cooperation Council. While Egypt has compared favourably with average scores for this disparate region for several years, the most recent figures from the WHO’s Regional Health Observatory (RHO) showed a decline across a range of factors in 2012, possibly as a result of the recent political upheaval in the country.

By The Numbers

Life expectancy in Egypt fell from 73.2 in 2011 to 70.4 in 2012, with the figure for females falling to 69, its lowest level since 1999. The under-five mortality rate was 21 per 1000 live births in 2012, compared to 19.6 in 2011. However, this is significantly better than both the region (58) and the rest of the world (51). The figure fell substantially between 1990 and 2010 for the region, from 100 deaths per 1000 live births to 58, but in Egypt the improvement was much more pronounced, dropping from 86 to 21. The biggest cause of infant mortality, at 30% of the total, was prematurity, with congenital anomalies accounting for 21%, other diseases 15% and birth asphyxia 11%. According to the UN‘s children’s fund, UNICEF, there are significant regional disparities in Egypt, 90% of under-five mortalities occur within the first year of a child’s life, and half of those deaths are within its first month.

The maternal mortality rate, this time measured against 100,000 live births, was far lower in Egypt, at 66, than the 250 average for the region, and 210 for the world. This may be in part explained by a higher incidence of trained medical personnel present at birth, with 79% of births attended by skilled health personnel in Egypt, compared to 63% for the region. However, the latest figures from the RHO show a marked decline in the proportion of Egyptian women able to access antenatal care from 74% in 2011 to 57% in 2012.

There were also falls in the percentage of one-year-olds being immunised between 2011 and 2012. The proportion receiving BCG jabs for tuberculosis fell from 98% to 95%; those receiving DPT inoculations for diphtheria, tetanus and pertussis from 97% to 93%; and those inoculated against measles from 99% to 98%. There was a rise in access to improved drinking water from 94% of the population in 2011 to 97.2% in 2012.

Staff

WHO figures showed a marked decline in the numbers of trained medical staff per 10,000 people between 2010 and 2012. The number of trained physicians dropped from 28.3 to 7.7; trained nurses and midwives from 34.9 to 13.8; dentists from 4.8 to 1.4; and pharmacists from 16.2 to 2.2. Egypt’s numbers in all of these categories were below the Eastern Mediterranean averages, which were 14 for physicians, 26 for nurses and midwives, 4.9 for pharmacists and 3.4 for dentists. Of the 23 countries in the region, Egypt and Syria were the only two showing a decline in the number of trained medical staff in all four categories over the two-year period. For numbers of trained medical staff per 10,000 population, Egypt fell from second out of 23 in 2010 to 15th, just below Iraq and Pakistan, in 2012. In terms of the number of nursing staff, including midwives, Egypt was ranked eighth in 2010, but slipped to 15th in 2012. It was top of the table for number of pharmacists in 2010, but fell in 2012, when it shared 11th place with Iraq, Djibouti and Tunisia. In 2010 it occupied eighth place in terms of the number of dentists per 10,000 people, but by 2012 was in 15th.

Departures

Dr Mohamed Hamad, the programme manager for health management and research at the Centre for Development Services, told OBG that many health professionals have emigrated to the US, Canada or Europe. Hamad was working at the Ministry of Health and Population (MoHP) in 2011, and said that many young physicians asked the MoHP for certificates to allow them to leave the country and practice abroad. “We had 10 applications every day for two months in late 2011,” he told OBG. “Many also leave the profession and do a different job, because the pay is so low for newly qualified doctors.”

Doctors Pay

According to the Egyptian Medical Syndicate, the professional body which represents physicians, the basic starting salary for a newly qualified doctor is LE320 ($45) per month.

Draft laws designed to improve the salaries and working conditions of medical staff were drawn up in 2012, but ratification was delayed by the change of government in 2013. The Medical Incentives Law came into effect in January 2014, but many medical staff were unhappy with the details, and doctors were on partial strikes – refusing to treat non-urgent cases – from March to May 2014. The strike was called off after ministers agreed to include some of the amendments demanded, while the syndicate agreed to postpone action over its remaining demands until the new parliament was elected at the end of 2014.

The Medical Incentives Law includes risk pay of LE120 ($17) a month, rising to LE200 ($28) by July 2016, as well as an increase in night shift and remote area allowances and bonuses that could amount to 450% of basic pay. A syndicate spokesperson told local press the bonuses and allowances could increase the take-home pay for a new entrant physician from LE320 ($45) a month to LE1430 ($203) a month.

Medical Schools

Despite the low pay associated with the profession, Egypt’s medical schools are training tens of thousands of new doctors every year. According to the Central Agency for Public Mobilisation and Statistics (CAPMAS), the government statistics agency, there were 60,946 medical students enrolled in Egyptian universities in 2011/12. The number of students graduating in medicine, dentistry and pharmacy rose significantly in the first decade of the millennium. In 2011/12, 10,967 medicine students graduated, a 71% increase on the 6400 in 2001/02. The number of pharmacy graduates rose by 53% over the same period from 7876 to 12,276, but the biggest jump was the 154% increase in the number of dentistry graduates, from 1508 in 2001/02 to 3828 in 2011/12.

In 2014 there were 11,000 students enrolled on medical degrees at Cairo’s Ain Shams University. Dr Yasser Soliman, the vice-dean of research at its medical school, told OBG that the faculty attracted foreign students from the Arab world, the rest of Africa and Malaysia who study alongside Egyptian students on courses delivered in English. “Some graduates stay in Egypt and some go abroad, for instance to the Gulf countries, the US, Europe or Canada,” Soliman said. “The level of our students is such that they nearly all pass the exams for the US, Canada or Europe. If they want to go to the Gulf, they are welcome there too.” The qualified medical graduates who remain in Egypt constitute a sizeable pool of trained health care professionals.

Access

According to the WHO, the number of primary care clinics in Egypt per 10,000 people was 0.6 in 2012, compared to the Eastern Mediterranean average of 1.73. In this category Egypt was ranked 17th out of 23 countries in the region in 2010, but had slipped to 18th in 2012. The number of available hospital beds shows a marked decline in the same period. In 2010 Egypt had 17.3 beds per 10,000 people, just above the regional average of 16.5, earning it 12th place. By 2012 this had fallen to 5.2, leaving Egypt ranked 20th, and well below the average of 14.8 beds. The only countries in the region with fewer hospital beds per capita were Iran, with 1.4 per 10,000, and Somalia and Southern Sudan, neither of which had any data available.

Although Egypt is moving towards a health model emphasising prevention and primary care over inpatient treatment, there is scope for expanding the number of hospital beds – this is where the private sector could come in, through independent investments, or through public-private partnerships, which are starting to emerge. However, looking beyond the statistics, the WHO representative in Egypt, Dr Henk Bekedam, told OBG that by global standards the country’s health care system has relatively strong infrastructure. “Most people live near a clinic, and its doctors and nurses are relatively well trained,” he said.

Fragmented

The Egyptian health care system is fragmented, with hospital services provided by a plethora of public sector bodies in addition to the private sector. According to CAPMAS, the total number of hospital beds fell by 16% between 2007 and 2012, from an all-time high of 152,424 to 128,473. The number and proportion of beds provided by private hospitals increased from 26,055, or 17% of the total, in 2007 to 31,653 – 25% of the total – in 2012. Of the remaining hospital beds, 40,801 were in MoHP facilities, 24,424 were in infirmaries supervised by the MoHP and 31,595 were in institutions run by other government-owned entities, including universities and a range of other ministries. For instance, there are 385 beds provided for people working for Egyptian National Railways.

“Fragmentation began in the late 1950s with good intentions. Employers would invest to ensure their workers had access to good medical facilities,” Hamad told OBG. “However, if we now consider the issue of infection control, for instance, the MoHP does not have access to military hospitals, hospitals run by other ministries or private hospitals. People do their own checks internally, but there is no overarching authority.”

Hepatitis C

Infection control in hospitals is a particularly critical issue. According to the Qatar Foundation Egypt has the world’s highest incidence of Hepatitis C, which is transmitted through infected blood, and the WHO calculates that 70-80% of new infections in the country occur in hospitals. It sees improvements in infection control as one of Egypt’s top three health priorities, alongside improved preventive medicine and increasing equality in provision across social classes.

Advances in molecular science mean the condition is now curable, but this makes little difference for the 12m Egyptians suffering from Hepatitis C because the treatments are so costly. In March 2014 US pharmaceuticals firm Gilead Sciences agreed to sell its Sovaldi pills to Egypt at a 99% discount. That means a 12-week course of treatment will cost $900 in Egypt when the first pills arrive in January 2015, compared to $84,000 in the US. Yet even at that price it would cost $10.8bn to cure everyone currently infected in the country.

While CAPMAS figures show a 115% increase in expenditure on health from the public purse in the five years from 2006/07 to 2011/12, when the government contributed LE22.5bn ($3.19bn), or 6.9% of its total expenditure, those who can afford it opt for private treatment. Out-of-pocket payments accounted for 58% of total health expenditure in 2012, according to the WHO.

Private infirmaries, such as the 140-bed Cleopatra Hospital in the Cairo suburb of Heliopolis, specialise in surgery performed by consultants who also work as professors in the city’s medical schools. Its operating lists are fully booked and the hospital is planning to expand its capacity. “The extension will be almost as big as the existing hospital,” said Dr Sherif El-Essawy, the hospital’s medical director. “People are increasingly in need of hospitals like this, and we do not have enough beds.”

The government does pay for patients from state hospitals to travel abroad for treatment, but has cut back on this expenditure in recent years. CAPMAS figures show state payments for treatment abroad peaked in 1998 at LE81m ($11.5m) and had fallen to LE35m ($5m) by 2007. In 2012 it spent just LE3m ($426,000) on overseas medical expenses. Egyptians with dual nationality enabling them to be treated in the UK, the US or Canada frequently travel abroad for treatment.

Social Health Insurance

The government is planning reforms to the country’s health insurance scheme, which are scheduled to be introduced in 2016, and the insurance sector is eyeing medical cover as a growth area. The reforms would see social health insurance (SHI) established, with the aim of ensuring universal access to care. The basic concept behind the proposal is that employees make monthly payments to a health insurance fund, with their employers making a further contribution. Payments would be compulsory for all but the poorest 20-30%, meaning that those with existing private insurance would have to pay into SHI too. Those employed in the informal sector would pay into the fund through unions and trade organisations.

Non-Communicable Diseases (NCDS)

Over the past few decades, the proportion of deaths attributable to communicable diseases has declined in Egypt, as the health authorities have had considerable success in tackling them. However, the proportion of deaths resulting from NCDs has risen, due not only to the decline in infectious disease but also to the rising prevalence of risk factors. In a country where malnutrition is a serious concern in poorer communities, with around 6% of Egypt’s children classed as underweight by the WHO, obesity is also a growing problem, along with various NCDs. Lifestyle conditions related to smoking, lack of exercise and unhealthy eating are taking their toll. The latest figures, which were published in 2011, attributed 39% of deaths to cardiovascular conditions, 11% to cancers, 3% each to respiratory diseases and diabetes, and 26% to other NCDs.

WHO figures for 2008 showed that 75% of women were overweight, and 46% of women over 20 were obese, while 60% of men were overweight, including 23% classed as obese. In the Eastern Mediterranean region as a whole, 25% of women and 13% of men were obese. WHO estimates for 2008 suggest 16% of the population had diabetes, 33% of males and 44% of females had high cholesterol, while 35% of men and women had high blood pressure. Egypt’s typical daily salt intake of 9.2g – compared to the recommended maximum of 6g – is one contributory factor.

Although WHO 2009 figures for smoking in Egypt did not include women, 40% of males over 15 years old smoked, compared to a regional average of 33%. Medical experts suspect the incidence among both men and women is much higher than is being reported, partly due to the social stigma attached to smoking for women.

Pharmaceuticals

Pharmaceuticals manufacturing is one of the longest-established industries in Egypt, and the potential in both the domestic and export markets is significant. Pharmaceuticals exports stood at $247m in 2011, according to the WTO. This ranked Egypt the third-largest exporter of the commodity in the MENA region, behind Israel and Jordan. “The number of pharmaceutical factories has increased from 50 in 2005 to more than 100 in 2014,” said Ali Al Meniawi, the COO of Delta Pharma. In its report for the fourth quarter of 2014, BMI forecast an uptick in growth in the near term, increasing the attractiveness of the pharmaceuticals market. Its headline expenditure projection for the segment predicted an increase from $2.41bn in 2013 to $2.48bn in 2014. “Given a proper regulatory system, the industry has the necessary infrastructure and facilities to compete with countries such as Saudi Arabia, South Africa and Jordan,” Emad Graiss, the managing director of Merck Serono, told OBG.

Challenges faced by pharmaceutical firms include the continued presence of counterfeit medicines, low prices and poor patent enforcement. “For research and development activity to develop, there must be an emphasis on establishing a clinical trial protocol enforced by law that protects patients and patents,” the chairman of Orchidia Pharma, Ossama Abbas, told OBG.

Domestic production has accounted for 93% of the local market by volume in recent years, but due to pricing issues only accounts for a little more than half of the market’s value. “Pricing regulation is in need of an urgent reform. Low-cost generic pharmaceutical prices have not been raised in over 10 years, but production costs have increased drastically,” Riad Armanous, the CEO of EVA Pharma, told OBG. Counterfeiting remains an issue due to uneven enforcement and a highly fragmented market, and fake, expired or illegal drugs are estimated to comprise 10-15% of the local market.

Outlook

In its 2014 constitution, the Egyptian government pledged to devote 3% of GDP to health care. With pressing matters of security and political stability facing the next government, health care workers are not anticipating radical reforms immediately. Yet the consensus is that reforms must come in the medium term to improve standards and services, reduce inefficiencies and inequality, and prepare the system for the pressures of dealing with a rapidly growing population. CAPMAS reported in February 2014 that the country’s population had reached 86m. WHO figures recorded a population growth rate of 2.4% in 2011 and 2% in 2012. “If you have a growth rate of 2.4%, then in 30 years your population will double, so Egypt could have a population of 180m in 2044,” Bekedam said.