Health System in Egypt

Health systems are undergoing rapid change and the requirements for conforming to the new challenges of changing demographics, disease patterns, emerging and re emerging diseases coupled with rising costs of health care delivery have forced a comprehensive review of health systems and their functioning.

As the countries examine their health systems in greater depth to adjust to new demands, the number and complexities of problems identified increases. Some health systems fail to provide the essential services and some are creaking under the strain of inefficient provision of services. A number of issues including governance in health, financing of health care, human resource imbalances, access and quality of health services, along with the impacts of reforms in other areas of the economies significantly affect the ability of health systems to deliver.

Decision-makers at all levels need to appraise the variation in health system performance, identify factors that influence it and articulate policies that will achieve better results in a variety of settings. Meaningful, comparable information on health system performance, and on key factors that explain performance variation, can strengthen the scientific foundations of health policy at national, regional and international levels.

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Comparison of performance across countries and over time can provide important insights into policies that improve performance and those that do not. The WHO regional office for Eastern Mediterranean has taken an initiative to develop a Regional Health Systems Observatory, whose main purpose is to contribute to the improvement of health system performance and outcomes in the countries of the EM region, in terms of better health, fair financing and responsiveness of health systems.

This will be achieved through the following closely inter-related functions: (i) Descriptive function that provides for an easily accessible database, that is constantly updated; (ii) Analytical function that draws lessons from success and failures and that can assist policy makers in the formulation of strategies; (iii) Prescriptive function that brings forward recommendations to policy makers; (iv) Monitoring function that focuses on aspects that can be improved; and (v) Capacity building function that aims to develop partnerships and share knowledge across the region.

One of the principal instruments for achieving the above objective is the development of health system profile of each of the member states. The EMRO Health Systems Profiles are country-based reports that provide a description and analysis of the health system and of reform initiatives in the respective countries. The profiles seek to provide comparative information to support policy-makers and analysts in the development of health systems in EMRO.

The profiles can be used to learn about various approaches to the organization, financing and delivery of health services; describe the process, content, and implementation of health care reform programs; highlight challenges and areas that require more in-depth analysis; and provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in different countries.

These profiles have been produced by country public health experts in collaboration with the Division of Health Systems & Services Development, WHO, EMRO based on standardized templates, comprehensive guidelines and a glossary of terms developed to help compile the profiles. A real challenge in the development of these health system profiles has been the wide variation in the availability of data on all aspects of health systems. The profiles are based on the most authentic sources of information available, which have been cited for ease of reference. For maintaining consistency and comparability in the sources of 5

Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO information, efforts have been made to use as a first source, the information published and available from a national source such as Ministries of Health, Finance, Labor, Welfare; National Statistics Organizations or reports of national surveys. In case information is not available from these sources then unpublished information from official sources or information published in unofficial sources are used. As a last resort, country-specific information published by international agencies and research papers published in international and local journals are used.

Since health systems are dynamic and ever changing, any additional information is welcome, which after proper verification, can be put up on the website of the Regional Observatory as this is an ongoing initiative and these profiles will be updated on regular intervals. The profiles along with summaries, template, guidelines and glossary of terms are available on the EMRO HSO website at www. who. int. healthobservatory It is hoped the member states, international agencies, academia and other stakeholders would use the information available in these profiles and actively participate to make this initiative a success.

I would like to acknowledge the efforts undertaken by the Division of Health Systems and Services Development to help countries of the region in better analyzing health system performance and in improving it. Regional Director Eastern Mediterranean Region World Health Organization 6 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 1 E XECUTIVE S UMMARY Egypt is going through a demographic and epidemiological transition that is affecting both the size and health status of the population. The population growth rate has fluctuated from a low of 1. 92% a year during 1966–1967, to 2. 5% annually during 1976–1986, later declining to 2% a year during 1980–1993 and 2. 1% annually in 2001. Changes in fertility and mortality rates have been the major source of population growth in Egypt. The population pyramid has a wide base with children aged under 15 representing 37% of the population, reflecting relatively high fertility in recent years. The proportion of children aged under 10 years is smaller than the proportion aged 10–14 years. The rate decreased from 80 in 1988 to 69 in 2000, so the proportion of productive group aged 15–64 years has increased.

The average age of the population has risen, with a life expectancy from birth of 65. 5 years for males in 1996 to 69. 2 years in 2006. It is higher for women than for men (69. 2 and 73. 6 years, respectively). Egypt is a lower-middle-income country with a per capita gross national product (GNP) that doubled between the years 1993 and 1999, from US $600 to $1200 (DHS, 2000). The Egyptian economy has witnessed a turnaround in growth performance following a period of economic slow-down that started in 1986.

The adoption of the open door policy in 1975 afforded the Egyptian economy a decade of rapid economic growth, supported by large inflows of foreign assistance, workers’ remittances, and oil and tourism revenues. The drop in oil prices in 1986 signaled the end of a decade of economic boost, underscoring the volatility of Egypt’s key revenues sources and the constraints of an inward-oriented growth strategy. With the success of the stabilization program in achieving its objectives, Egypt has been successful in reversing the slow growth rates that characterized the period 1991–1995.

Real GDP grew annually at an average of 3. 8% during 1993–1996 and at an average of 6% during 1996–1998. Inflation has been brought down from a peak of 21% in 1992 to 7% in 1996 and 3. 6% by 2000 (UNDP, 2000). While public expenditure on health in terms of budget share appears to be low in Egypt, overall spending at 3. 7% of GDP is also low, when compared to other comparable income countries. The Ministry of Health and Population (MOHP) budget, as part of the entire Government budget, increased from 2. 2% in 1995/1996 to 3. % in 2000/2001 and the MOHP expenditure per capita increased from LE26. 8 in 1996 to LE56. 7 in 2001. The health financing system in Egypt today manifests significant systemic inefficiencies and inequities that severely limit the effectiveness of the health system as a whole. Any attempts to expand the scope of services or increase the revenues and expenditures on health care without first addressing these systemic bottlenecks in the health financing system will result in further exacerbating the inefficiencies and inequities in the system.

The existing system of health financing mechanisms in place today, whether it is through the general revenues Ministry of Finance or the Health Insurance Organization system or through private spending, establishes a regressive pattern of resource mobilization and resource allocation. Inequities are evident across many dimensions, in terms of income levels, gender, geographical distribution (rural and urban, and by governorate levels), and health outcomes. 7 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO

The coverage of the Egyptian population with the National Health Insurance scheme is increasing through the addition of new population groups under the umbrella of social health insurance, for example school children and newborn children. In the year 1980, the coverage was 4% of the total population, and it doubled in 1990. In the year 1995, it reached 36% and increased over the last ten years to 45%. Out of pocket spending has been rising over past decade and currently stands at 62%. HIO does not reach 80% of the private sector workforce.

Highest governmental healthcare spend is proportionately in lowest income quintile. The 1952 Constitution pronounced free medical care as a basic right for all Egyptians. The Government has been the sole provider and financier of all primary/preventive and most inpatient curative care in Egypt. However, over the past two decades governmental budgetary constraints have resulted in relatively stagnant health expenditures. The structural adjustment program has also reduced the government's resource position vis-a-vis allocation for social services sectors in general, and health services in particular.

The Egyptian health system has a pluralistic nature with a wide range of health care providers competing and complementing each other, allowing clients freedom of choice when seeking care according to their needs and ability to pay. However, the Government is committed to providing health care to poor and unprivileged population groups. Parallel to, and related to, its demographic transition, Egypt is currently facing an epidemiological transition that is characterized by: ¦ Reduced mortality rates among infants and children from diarrhea, immunization-preventable diseases and respiratory infections. Rising prevalence of risk factors such as obesity, smoking and hypertension, responsible for chronic diseases. ¦ A changing socioeconomic environment leading to different diets, increased industrialization, and increased motor vehicle traffic accidents. The distribution of the burden of diseases has changed from a predominance of infectious and parasitic diseases to a different mortality pattern whereby cardiovascular diseases are currently the leading cause of mortality (45% in 1991, compared to 12% in 1970 and 6. 3% in 2001).

Egypt is therefore affected by a dual burden of disease, thus associating the morbidity and mortality patterns of developing countries with those induced by modernization. As a result of the demographic and epidemiological transition, the major health and population challenges are: 1. Population growth 2. Burden of endemic and infectious diseases 3. Maternal, infant and childhood mortality 4. Burden of chronic diseases, renal failure and cancer 5. Injuries and accidents 6. Smoking, other addictions, and their complications 7. Disabilities and congenital anomalies 8 Health Systems Profile- Egypt

Regional Health Systems Observatory- EMRO 8. Human resources (capabilities, skills, knowledge, allocation, salaries and incentives) 9. Infrastructure (buildings, equipment, furniture and maintenance) 10. Basic public services (housing, unplanned areas and slums, potable water, sewage disposal). The health system has significant strengths and weaknesses resulting from its continuing evolution. The performance of the sector with respect to health services, human resources, physical infrastructure, financing, organization and management, and the pharmaceutical sector will be assessed in following eight sections.

Ministry of Health and Population has decided on a reform program based on the strengths of the current system, while at the same time rectifying its weaknesses. The Government of Egypt has embarked on a major restructuring of the health sector. This reform was deemed necessary because the MOHP and its main partners had identified fragmentation in the delivery of health services, excessive reliance specialist care and low primary care service quality as the main constraints to achieving universal coverage.

The Egyptian Health Sector Reform Program (HSRP) was officially launched in 1997. The World Bank (WB) started its contribution by designing the Master Plan for Montazah Health District in Alexandria Governorate, in May 1998. By the following year, in 1999, United States Agency for International Development (USAID) was the first donor to begin field-level operations, while the European Commission (EC) joined the HSRP in November 1999. The African Development Bank (ADB) initiated its work through designing Master Plans for three health districts in June 2003.

The most recent partner at HSRP is the Austrian Government, which directs its participation to improving the district hospitals as part of health district approach. The overall aim of the HSRP is twofold. Firstly to introduce a quality basic package of primary health care services, contribute to the establishment of a decentralized (district) service system and improve the availability and use of health services. Secondly to introduce institutional structural reform based on the concept of splitting purchasing/providing and the regulatory functions of the Ministry of Health and Population.

Coverage would be provided by a National Social Insurance System. The ultimate goal of health sector reform initiatives is to improve the health status of the population, including reductions in infant, under-five, maternal mortality rates and population growth rates and the burden of infectious disease. The HSRP has meanwhile initiated a new primary care strategy in accredited facilities, known as Family Health Units (FHU’s). Facilities are being contracted by a purchasing agency -the Family Health Fund (FHF) - to provide services to the population.

It is envisaged that the HSRP will gradually extend its scope to the secondary level by establishing “District Provider Organizations”. The FHF will consequently develop in the direction of a full purchasing agency of services from the public and private sector. The newly introduced Family Health Model (FHM) constitutes one of the cornerstones of the reform program. It brings high quality services to the patient and will integrate most of the vertical programs into the Basic Benefit Package of services.

To date the FHM has been introduced in 817 health facilities, which present 18% of the total public primary health care facilities. HSRP has an ambitious five years plan, by the end of year 2010, to cover the entire public primary health care facilities with the Family Health Model. The Egyptian Health Sector Reform Program went through several stages, including the preparatory stage from 1994 to 1996. During this stage, several valuable studies were conducted and used later to develop the “Strategies for Health Sector Change” study. 9 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO

This was an analytical report on the Egyptian health sector. Designing the health Master Plans stage for the three pilot governorates followed this. Experimenting stage of the Family Health Model took place in one of the primary health care facilities, which took about two years to implement. This was followed by piloting stage of the Model in three governorates followed by another two governorates and included activities such as: Building staff pattern, designing the contents of the Basic Benefits Package and Essential Drug List, and other components of the Family Health Model.

The Program has shifted its strategy in March 2003 from health facility oriented approach to the district approach, which was called the District Provider Organization. As of 2005, the HSRP has gradually expanded its operations to ten additional governorates, pushing the total number of involved governorates to 15, which presents more than 50% of the country coverage.

The Health Reform Program has three main components; (1) Service component as seen in the Family Health Mode, (2) Mandate role and functions of the Ministry of Health and Population, and (3) Introduction of a sustainable universal health insurance system. It is envisaged that all three goals and objectives can be achieved in an Integrated District Health System model. All the necessary elements are available and the Sector for Technical Support and Projects (STSP) is in developing process for an integrated health system based on a district that is evaluated internally and externally and be replicable.

The Integrated District Health System (IDHS) is the district that covers the following criteria; (1) fully implements the District Provider Organization, (2) has financial sustainability, (3) separates providing from financing of health services, (4) implements the content of the district health coverage plan, (5) provides basic benefits and secondary care packages through public, private and NGO, (6) and applies quarterly measures for the achievements of HSRP’s five objectives. 10 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 2 S OCIO E CONOMIC G EOPOLITICAL M APPING 2. Socio-cultural Factors Table 2-1 Socio-cultural indicators Indicators 1990 1995 2000 2004 - - - - Literacy Total: 48. 8 (92) 57. 7 (98) 67. 4 (02) 69. 4 02) Female Literacy to total literacy: 35. 3 (92) 65. 9 (98) 63. 4 (01) 67. 4 02) Women % of Workforce 29. 2(93) 18. 0(96) 18. 5(01) 21. 8(02) Primary School enrollment 98. 0(92) 98. 5(98) 91. 7(01) 99. 2(02) % Female Primary school pupils 80. 4(92) 84. 5(98) 93. 2 107. 1(02) %Urban Population 44. 0(86) 43. 0(96) 42. 8 57. 6 Human Development Index: Source: NICHP Report, Ministry of Health and Population, 2005. Egypt Human Development Report, 1995, 1999, 2003, 2004. . 2 Economy Key economic trends, policies and reforms Lack of substantial progress on economic reform since the mid 1990s has limited foreign direct investment in Egypt and kept annual GDP growth in the range of 2%-3% in 200103. However, in 2004 Egypt implemented several measures to boost foreign direct investment. In September 2004, Egypt pushed through custom reforms, proposed income and corporate tax reforms, reduced energy subsidies, and privatized several enterprises. The budget deficit rose to an estimated 8% of GDP in 2004 compared to 6. 1% of GDP the previous year, in part as a result of these reforms.

Monetary pressures on an overvalued Egyptian pound led the government to float the currency in January 2003, leading to a sharp drop in its value and consequent inflationary pressure. In 2004, the Central Bank implemented measures to improve currency liquidity. Egypt reached record tourism levels, despite the Taba and Nuweiba bombings in September 2004. The development of an export market for natural gas is a bright spot for future growth prospects, but improvement in the capital-intensive hydrocarbons sector does little to reduce Egypt's persistent unemployment

Table 2-2 Economic Indicators Indicators 1990 GNI per Capita (Atlas method) current US$ 2000 2004 NA GNI per capita (PPP) Current International Real GDP Growth (%) 1995 1. 9 (91-92) 5 (95-96) 3. 4 (00-01) 4 (03-04) 11 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Real GDP per Capita ($) (91- 92) 769 1,285 1,036 9. 2 (91-92) Unemployment % (estimates) 1,143 9. 6 (91-92) 9. 0 (01) 10. 2 (03) Source: Egypt Human Development Report, 2003. Ministry of Foreign Trade, Egypt, Monthly Economic Digest, February 2005. Table 2-3 Major Imports and Exports Major Exports:

Crude oil and petroleum products, cotton, textiles, metal products and chemicals. Major Imports Machinery and equipment, foodstuffs, chemicals, wood products and fuels. 2. 3 Geography and Climate Map of Egypt Arab Republic of Egypt is located at the northern Africa, bordering the Mediterranean Sea, between Libya and the Gaza Strip, and the Red Sea north of Sudan, and includes the Asian Sinai Peninsula. Total area is 1,001,450 sq km (land: 995,450 sq km, water: 6,000 sq km). A total of 2,665 km border countries: Gaza Strip 11 km, Israel 266 km, Libya 1,115 km, Sudan 1,273 km.

Coastline is 2,450 km. The climate is desert; hot, dry summers with moderate winters. Natural resources; petroleum, natural gas, iron ore, phosphates, manganese, limestone, gypsum, talc, asbestos, lead and zinc. 2. 4 Political/ Administrative Structure The chief of state is the President, head of government is the Prime Minister. Bicameral system consists of the People's Assembly or Majlis al-Sha'b (454 seats; 444 elected by popular vote, 10 appointed by the president; members serve five-year terms) and the 12 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO

Advisory Council or Majlis al-Shura - which functions only in a consultative role (264 seats; 176 elected by popular vote, 88 appointed by the president; members serve sixyear terms; mid-term elections for half the members). People's Assembly election is in three phase voting, last held 19 October, 29 October, 8 November 2000 (next to be held October-November 2005); Advisory Council - last held May-June 2004. The Shoura Council was established constitutionally in 1980. The Shoura Council is mainly a “think-tank” to advise the Government on national policies.

A committee of the Shoura Council on Health, Population and Environment examines issues relevant to these areas prior to their discussion in the Shoura Council’s plenary sessions. Although it does not have a direct legislative role, laws impacting significantly on broad government policy are required to be discussed by the Shoura Council before being passed to the People’s Assembly Laws, before going to the plenary sessions of Parliament, are referred for preliminary study to the relevant committees. These specific committees are currently 22 in number; an example is the Committee for Health and Environment.

This committee, consisting solely of Members of Parliament, often invites experts to its meetings for the purpose of obtaining a more comprehensive view of topics under study. The committee influences health policy changes planned for the future 13 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 3 H EALTH STATUS AND DEMOGRAPHICS 3. 1 Health Status Indicators Table 3. 1 Health Status Indicators 1990-2005 Indicators 1990 1995 2000 2004 2005 65. 3 (92) 66. 9 (98) 67. 1 (01) 70. 1 (02) - - - - - - 63 66 24. 5 22. 4 20. 5 - 3. 9 (97) 33. 8 28. 6 26. 2 174 (92) 96 (98) 84 (01) 68 (02) 3 - - - - - 26 29. 8 28. 7 NA 17. 6 Prevalence of wasting 3. 4 4. 6 Source: NICHP Report, Ministry of Health and Population,2005. 2. 5 NA 3. 9 Life Expectancy at Birth HALE Infant Mortality Rate Probability of dying before 5th birthday/1000 Maternal Mortality ratio Percent of Normal birth weight babies Prevalence of stunting Egypt Human Development Report,2004 Table 3-2 Indicators of Health Status by Gender and by urban rural 2006 Indicators Urban Rural Male Female Life expectancy at birth - - 69. 2 73. 6 HALE - - - - Infant Mortality Rate 27. 7 15. 3 - - Probability of dying before 5th birthday/1000 3. 9 20. 6 27. 6 24. 7 Maternal Mortality Ratio - - - - Percent of Normal Birth Weight Babies - - - - - - - Prevalence of stunning/wasting Source: NICHP Report, Ministry of Health and Population,2005. WHO Web Site,August 2005 14 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Table 3-3 Top 10 causes of Mortality Mortality Y2005 Rank Intra-cerebral hemorrhage 21,473 Essential (primary) hypertension 20,354 Fibrosis and cirrhosis of liver 18,434 Hepatic failure, not elsewhere classified 11,353 Atherosclerosis 10,800 Arterial embolism and thrombosis 8,233 Elevated blood glucose level ,000 Acute myocardial infarction 6,645 Cerebral infarction 6,334 Others 320,011 Total 431,637 Source: NICHP Report, Ministry of Health and Population, 2005. The Burden of Disease and Injury in Egypt (Mortality and Morbidity). 2004. 3. 2 Demography Demographic patterns and trends Total population of Arab Republic of Egypt is 77,505,756 (July 2005 est. ). The age distribution is 0-14 years presents 33% (male 13,106,043/female 12,483,899), 15-64 years presents 62. 6% (male 24,531,266/female 23,972,216), 65 years and over presents 4. 4% (male 1,457,097/ female 1,955,235) (2005 est. ).

Net migration rate is -0. 22 migrant(s)/1,000 population (2005 est. ). Sex ratio: at birth 1. 05 male(s)/female, under 15 years it is 1. 05 male(s)/ female, 15-64 years it is 1. 02 male(s)/female, 65 years and over it is 0. 74 male(s)/female, for the total population it is 1. 02 male(s)/female (2005 est. ) The median age is 23. 68 years, 23. 31 years for males and 24. 05 years for females (2005 est. ). Eastern Hamitic stock (Egyptians and Bedouins) presents 99%, Greek, Nubian, Armenian, other European (primarily Italian and French) presents 1%. Muslim (mostly Sunni) 94%, Coptic Christian and other 6%.

Arabic is the official language, English and French are widely understood by educated classes. 57. 7% of the population (age 15 and over) can read and write. Male presents 68. 3% and female presents female: 46. 9% (2003 est. ). 15 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Table 3-4 Demographic Indicators Indicators 1990 1995 2000 2004 2005 - 27. 9 1997 27. 9 27. 0 (03) 25. 8 (05) - 6. 4 1997 6. 3 6. 4 (03) 6. 4 (05) 2. 4 (60. 86) 2. 08 (86-96) 2. 3 (96-02) 2. 0 (03) 19. 1 (05) 74. 7 1992 69. 7 1998 69. 9 (01) 69. 9 (02) - - 37. 8 1996 38. 8 (03) 37. 4 - 3. 90 1992

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