Despite advances, work remains to improve access and quality of care in Egypt's health care sector

Continued efforts to address the health care needs of its large and growing population has resulted in varied opportunities for development of Egypt’s health care space, particularly in the form of private sector investment. While the country has continued to see some positive steps, especially in the arena of primary care access and infant and maternal care, progress has been stalled on some other priorities, including the long-promised universal health insurance initiative.

Overall, continued efforts will be best supported by increasingly streamlined cooperation among all the sector actors, as well as further investment in hospital infrastructure and human resources.

Key Indicators

In Egypt’s efforts to reach basic international health benchmarks as set by the UN Millennium Development Goals (MDG), progress has been notable. According to UNICEF’s 2015 “Children in Egypt Statistical Digest”, there has been a steady decrease in the under-five mortality rate, dropping almost by half from 54.3 deaths per 1000 live births in 2000 to 27 in 2014. Similarly, the overall infant mortality rate has plummeted from 43.5 deaths per 1000 live births in 2000 to 22 deaths in 2014. However, both figures vary according to geography, with the highest under-five and infant mortality rates both found in rural Upper Egypt (42 and 35, respectively), as well as with income level.

For both under-five and infant mortality, the rates in the poorest quintile of the population are almost twice as high as those in the wealthiest. More positively, as reported in the 2014 Egypt Demographic and Health Survey (EDHS), 92% of births in Egypt are assisted by a doctor or nurse/midwife, with 87% of women now giving birth in a health care facility.

Progress with regard to addressing tuberculosis is another bright spot, thanks in large part to persistent efforts by the Ministry of Health and Population (MoHP). Egypt has achieved the MDG target of reducing the incidence and death rates of tuberculosis by 50% from the rate of 34 cases per 100,000 people in 1990 to 15 cases in 2015. International health organisations credit this in large part to the implementation of compulsory vaccines for all newborns within two weeks of birth. Similarly, the death rate from tuberculosis has been significantly reduced from four deaths per 100,000 people in 1990 to 0.24 deaths in 2015.

Nutrition

Unfortunately, the statistics on child and adult nutrition have remained stagnant or, in some cases, are getting worse. According to data compiled in a 2015 World Bank report, around one in five children under the age of five are classified as stunted and one in 10 are classified as severely stunted. UNICEF reported that wasting – a weight-for-height measurement that is associated with acute starvation or chronic nutritional problems – has actually increased in the last 15 years from 3% in 2010 to 8.4% in 2014. The proportion of children who are moderately to severely underweight also rose from 3.7% in 2000 to 5.5% in 2014. These statistics have made malnutrition a key area of engagement for international donors. For example, USAID, in cooperation with the Tufts University Nutrition Lab, has an ongoing $1.2m project to research the causes and solutions for child nutrition and stunting in Egypt.

A Complex System

International health organisations, including the World Health Organisation (WHO) and UNICEF, continue to express ongoing concern about the highly convoluted structure of Egypt’s health care system. In broad strokes, the MoHP oversees the country’s overall health policy, Egypt’s public Health Insurance Organisation (HIO) and the provision of public health services. The Ministry of Higher Education is responsible for health education. In addition, other ministries, the defence establishment, a variety of private for-profit and non-profit providers, as well as some 22 international donors are also a part of the scene, according to Magdy El Sanady, chief of UNICEF’s child survival and development section. This fragmented structure contributes to poor resource allocation and duplication of efforts, according to the WHO.

Government Updates

The MoHP was exempt from the large Cabinet reshuffle that took place in March 2016, with Ahmed Emad El Din Rady remaining in his role as minister of health. El Din Rady has been outspoken in the local press about the challenges his sector faces, including the shortage of medical workers and low funding levels. According to “Health Care Sector Report, Egypt 2015”, published by regional investment bank Multiples, more than 200 hospitals and 3800 clinics require complete renovation.

As is the case with education spending levels, as per the 2014 constitution, ratified in January that year, the government is required to spend 3% of GDP on health initiatives. Based on the most recent data available from the World Bank, public health expenditure stood at 2.2% of GDP in 2014. Turkey, a comparably large regional health care market of around 75m people, spent 4.2%, while the world average was 6% of GDP. As a percentage of overall government spending, health care spending actually decreased from 5.37% in FY 2014/15 to 5.2% in FY 2015/16, as reported by Egypt’s Central Agency for Public Mobilisation and Statistics (CAPMAS).

However, the government is making tangible efforts to boost both government and private investment in health care. In April 2016 the Ministry of Finance announced in the local press that it aims to spend 5.7% of the FY 2016/17 budget on health, which will amount to around LE53.3bn (equivalent to $2.8bn as of December 2016) up from LE49.3bn ($2.6bn) in FY 2015/16.

In addition, El Sanady told OBG that he believes the MoHP’s current health care quality improvement project is a crucial step in the right direction. The project – which has $76m in support from the World Bank – consists of establishing and nationally accrediting 1000 family health units in five governorates (51 districts) in Upper Egypt where the greatest disparities exist.

Private Sector Involvement

As Ahmed Yasser Soliman, CEO of Alameda Health Care’s private As Salam International Hospital, told OBG, “Demand for health care in Egypt is still greater than supply, whether public or private. There is big potential for expansion in the private sector here.” This expansion has been progressing over the course of the past decade. According to CAPMAS, in 2002 only 16.3% of hospital beds were in private facilities; however, this figure had risen to 25.3% by 2014. Similarly, when it comes to health units that have beds at all, in 2014 a full 68% of these units were private, as opposed to 48% in 2002.

One area of ongoing investment is in the physical infrastructure of hospitals. Alameda Health Care, a private health care group established in Egypt in 1999, has announced plans to open an additional facility, Katameya International Hospital with 160 beds, by 2017. The Dubai-based Abraaj Group also announced in June 2016 that it raised LE360m ($19.1m) through an initial public offering on the Egyptian Exchange for its partner, Cleopatra Hospital Company, the largest private hospital group in Egypt in terms of the number of hospital beds and hospitals, to fund expansion.

There have also been announcements for investment in the health care manufacturing industry. In May 2016 Huda Yassa, chairwoman of the Egypt-based Arab Women Investors Union, announced that the group is planning to facilitate investment of around $900m in health care projects in Egypt in the form of joint ventures with the government. According to local press reports, specific projects include two pharmaceuticals manufacturing factories in the eastern town of Sohag, with estimated values of $200m and $250m, as well as a $200m cell manufacturing unit and a $250m blood derivatives factory. These would build on Egypt’s established and growing pharmaceuticals industry, which continues to make strides in spite of a variety of challenges (see analysis). With regard to future investment, El Sanady said that external private and public support would be most valuable on the technical side, helping to promote evidence-based interventions and introduction of new protocols or technologies.

Individual Spending & Coverage

According to the World Bank, 72% of total health expenditures across Egypt came from out-of-pocket spending as of 2015. As reported in 2015 by the Multiples report, this means that the average Egyptian family spends 9.2% of their annual income on health care, for an average of LE2416 ($128). This is markedly higher for wealthier, urban governorates, where average annual spending per family is LE33,718 ($1790). These figures are a large part of why Egypt has announced its goal of universal health coverage by 2030. The 2014 constitution includes a requirement for a “comprehensive health insurance system covering all diseases for all Egyptians”.

Financing in Egypt’s health system is fragmented and complex, consisting of numerous separate entities. The HIO provides coverage to some 58% of the population, primarily children in school, widows and pensioners. The MoHP and the Programme for Treatment at the Expense of the State are intended to provide free or subsidised health services to those not insured, while in some governorates, family health funds provide a basic benefit package of health services. Private insurance has become increasingly popular. The Egyptian State Information Service estimates that 30% of the population are enrolled in private health insurance plans.

In May 2016 El Din Rady announced in the local press that the draft of the new health insurance bill was complete and ready to be sent to parliament for ratification after a long and highly publicised debate with the Doctors Syndicate. The bill aims to provide health insurance to low-income citizens, making use of new medical insurance cards linked to families, rather than individuals. El Sanady told OBG, the long-term vision is to create a system similar to the National Health Service in the UK, in which a strong, large network of family health providers acts as a gatekeeper to specialist care, making referrals to secondary treatment options as needed. In addition, it would share the characteristic of a separation between provision and financing of care.

Communicable Diseases

While certain global health epidemics – including HIV and malaria – do not represent the health risks they do in other African countries, Egypt still struggles with a variety of communicable and non-communicable diseases (NCDs). The proportion of deaths attributable to communicable diseases has declined, but Hepatitis B and C both remain leading causes of death across the country. The WHO estimates that roughly 7% of Egyptians suffer from Hepatitis C. However, in recent years some headway has been made in the battle against the virus. In March 2015 the first factory was opened in Egypt for production of Sofosbuvir, a medication used to treat the virus. Pharmed Healthcare, a joint venture between Indian, UAE and Egyptian partners, oversaw the opening of the factory, having obtained a licence from US-based Gilead Sciences to manufacture and market the drug in Egypt. The pills are distributed for free in high-risk areas.

Non-Communicable Diseases

NCDs such as cardiovascular diseases, diabetes, cancer and chronic respiratory diseases, are estimated to account for 82% of all deaths and 67% of premature deaths in Egypt, according to the WHO. Based on findings in the MoHP’s 2015 Health Issues Survey, there are a variety of lifestyle choices that could be contributing to these rates. According to the survey responses, just under 50% of men between 15-59 smoke tobacco products, and 75% of women and 60% of men aged between 15 and 59 are overweight or obese. Diabetes is of particular growing concern. The 2015 Multiples report puts the prevalence of diabetes at 9% of the population in 2015.

Mental Health

There has also been a recent spotlight on mental health disorders. According to a 2015 World Bank study, depressive disorders and anxiety are among the main causes of disability and death in Egyptian women aged 15-49. Substance addiction is on the rise among Egyptian men, behaviour that is often considered a coping mechanism for mental health illness. Unfortunately, mental health services are still underfunded, making up only 2% of the total government health budget and only 5% of undergraduate training hours at medical school, according to the study. The research also noted that there are only 15 mental health hospitals nationwide.

Human Resources

El Sanady told OBG that one of the greatest challenges for the medical system remains ensuring sustainable, quality service across the country. “I think the high staff turnover at the primary-care level is a chronic problem, and this relates very much to the discontinuity of services and the quality of service provision and drags the effort.” He explained that the perception is that family medicine – particularly in rural areas – is not viewed as prestigiously as the state-of-the-art work of curative medicine. “There needs to be promotion of the idea of the importance of having doctors working at the primary-care level, providing the first line of defence against diseases.”

Outlook

While there is still some heavy lifting to be done, Egypt is likely to make progress on goals for quality and equitable health care access, if the government can live up to its commitment to increase public spending on health initiatives, attract additional foreign investment for facility upgrades and research, and increase equity of access through passage of the universal health coverage law. In addition, if the structures for governing and financing the health care system can be streamlined and resources better allocated within it, quality of service would be likely to increase.