Regional profile – Egypt
The burden of over population

Despite a well-established healthcare infrastructure, Egypt’s Ministry of Health and Population is struggling to provide equitable healthcare to all its people. Callan Emery reports.



Healthcare in Egypt is as old as the pharaohs. It flourished during the golden age of Islam, a time when Europe was under the oppressive fist of the Holy Roman Empire.

Today, Egypt has hospitals and clinics spread throughout the country offering healthcare to all its people and some of these facilities are in the top order. The country has ample healthcare training facilities at several universities across the country which have medical faculties. But, despite this well established healthcare infrastructure, Egypt struggles with the burden of overpopulation, chronic urban pollution and many of the diseases of both the developing and developed world.

Ancient Egypt

Historical records of healthcare in Egypt are some f the oldest in the world dating back more than 5,000 years to the pharaohs of ancient Egypt. The ancient Egyptians were advanced medical practitioners for their time.

They had a thorough knowledge of the human anatomy and healing, evidenced by their extensive mummification practices which involved the removal of most of the internal organs including the brain, lungs, pancreas, liver, spleen, heart and intestine. The ancient Egyptians produced several medicinal compendiums, the largest of which was compiled by Hermes, a Greek healer who studied in Egypt. Among their skills they practiced surgery, dentistry and performed autopsies.

They prescribed remedies made from plants, animals and minerals. And, in testament to their skill in both early and later pharoanic dynasties, scholars from ancient Greece and other parts of the Mediterranean travelled to the country to study the medical practices of ancient Egypt. The most well known of the ancient Egyptian medical records is the Ebers Papyrus, a 110-page document dated to the reign of the pharaoh Amenhotep (circa 1534 BC).

The Ebers Papyrus consists of a collection of many different medical texts in a rather haphazard order, covering such topics as: magical spells designed to provide protection from supernatural intervention on diagnosis and treatment; diseases of the stomach with a focus on intestinal parasites; skin diseases, with remedies in three categories – irritative, exfoliative and ulcerative; diseases of the anus; diseases of the head; conditions concerning hair; traumatic injuries and wounds; diseases of the extremities such as toes, fingers, and legs; diseases of the tongue; dental conditions; diseases of the ear, nose, and throat; and gynecological conditions.

Magic, the intervention of the gods and the physician’s medical skill were intricately intertwined in the process of diagnosis, treatment and healing during pharoanic times.

The golden age of Islam

During the period from the 9th to the 12th centuries AD Islamic academy lead the world in many pursuits of the intellect including philosophy, medicine, mathematics, astronomy and literature.

It was during this period of high academy that Islam made its indelible mark on Cairo – still evident today in the architecturally striking “old Cairo” part of the sprawling city. Following the fall of Bagdad to the Mongols in 1258 and with Islamic culture declining in Spain, Cairo became the seat of learning in the Arabic world.

Student to this day continue to graduate from Cairo’s Al Azhar University, the world’s oldest. And at the Madrassa and Mausoleum of Qala'un in Cairo is a hospital which, remarkably, has been operational for the past 700 years, although it is currently being renovated. One of the most well known physicians from this period was Ibn El Nafis (1208-1288AD) who was born in Damascus but spent most of his life as a physician in Cairo.

He made several major contributions to medicine particularly regarding blood circulation. He was the first head of Mansuriya Hospital in Cairo and Dean of the Mansuriya School of Medicine. (See Islamic physicians in history, page 94). Great strides were made in medicine during this period and the contribution and influence of Islamic physicians such as Ibn El Nafis, Ibn Sarabiyun, Razis and Ibn Sina, is widely respected in modern medicine.

One magnificent story from that period highlighting the high regard of Islamic physicians took place during the reign of the famous Salah Al Din, who ruled Egypt around 1175. During battle with King Richard 1 of England in 1191, Salah El Din demonstrated immense chivalry by offering King Richard the services of his personal physician to treat his wounds. Following this magnanimous gesture Salah Al Din was regarded as a great man of honour throughout Christian Medieval Europe.

The burden of modernity

Modern day Egypt and the scene is rather different. Although the country has more than 4,000 primary healthcare centres offering all Egyptians access to healthcare, many of the hospitals and clinics are overcrowded and the quality of service varies sharply. In essence the country is burdened with overpopulation and all the problems that this manifests – poverty, pollution, disease, equitable access to healthcare.



Although Egypt’s population is essentially concentrated along the fertile banks of the River Nile, as it always has been, a large proportion – 42% according to WHO 2003 figures – is urbanised. It is estimated that there are now 20 million people in Cairo alone, making it one of the world’s most populous cities. Egypt’s total population is around 70 million (68 million according to WHO stats from 2003). Dealing with population growth is a key challenge for the government. Even Egypt’s ubiquitous ministry of health is known officially as the Ministry of Health and Population (MoHP).

“We have about 1.2 million to 2 million infants born each year,” Dr Nasr El Sayed, under secretary for preventative affairs, MoHP, told Middle East Health in Cairo. “About 40% of the population is under 20 years of age, which means we need to build more schools and more healthcare facilities,” he said. “This is our main challenge.”

Dr El Sayed remarked that Egypt has had family planning programmes in place for 20 years. “They are effective,” he said. “Without these programmes the population would be around 80 million now.” According to the 2001 figures from WHO the Egyptian Government allocated only 3.3% of its total budget to the MoHP. In 2000 MoHP spend accounted for only 1% of the country’s GNP.

By comparison oil-rich Saudi Arabia allocated 7.1% of its total budget to healthcare, representing around 2% of GNP. Libya allocated around 11.3% of it total budget to the MoH – about 1.5% of GNP. Iran allocated 8% of its budget to health provision, about 1.6% of GNP. Pakistan allotted 3.5% of its national budget to healthcare – 0.7 of GNP. Syria allocated 3.8% of its budget and Oman 5.8%.

From these figures it is clear that the provision of healthcare is relatively low on the list of priorities for the Egyptian Government. This point was made by Dr Mohamed Nabil Mawsouf, owner of the Cairo Medical Clinic, professor of pain management at Cairo University and head of the Ozone Therapy Unit at the university. He told Middle East Health in Cairo that there were several problems with the provision of healthcare in Egypt. He said there were too many patients at each hospital, especially government hospitals, which choked resources.

“There is not sufficient financial support. The government budget for healthcare is too low. It is below standard,” he said. A study published in 1999 by the Harvard School of Public Health entitled The Distribution of Health Care Resources in Egypt: Implications for Equity (www.hsph.harvard.edu/ihsg/p ublications/pdf/No-81.PDF) also supports the argument of inadequate and inequitable spend on healthcare by the Egyptian Government. The report concludes that spending on public health in Egypt is biased towards the higher income groups, leaving the poor, who are often the ones most in need of healthcare, struggling to access good quality health services. The authors point out five major reasons why this is so:

(i) A substantial proportion of government health spending through several large programmes other than MoH, which receive substantial government subsidies, but which by their very nature tend to benefit only the urban and formal sector populations.

(ii) Lack of any apparent mechanism to use MoH geographical allocations as a method of counteracting the geographical imbalance in healthcare resources due to private spending and other government programmes.

(iii) Public spending on health through social insurance programmes is in practice a regressive mechanism of funding health services, as observed in other countries with large rural populations and informal sectors.

(iv) Lower utilisation rates of all health services by lower income groups, which ensures that they utilise fewer resources than might be expected from government health programmes.

(v) Lack of significant concern with equity as a major policy goal in the health sector, which manifests itself in little discussion of distributional issues, or with high priority being attached to the distributional consequences of government health policies.

The authors point out that MoH services are the major source of healthcare services for the poor, and for most rural Egyptians.

They suggest “the Government of Egypt should give serious consideration to allocating any new increments in government healthcare spending to the MoH budget and not to further expansion of university and teaching hospitals and the various social insurance programmes. “If any such increase in resources can be made selectively available to the poorer and least healthy governorates, this might be expected to have a greater impact on the poor.”

Reform
Dr Emam Mohamed Moussa, under secretary and general director for the Technical Office, MoHP, told Middle East Health in an interview in Cairo: “In 1997 Egypt embarked on a reform programme for its healthcare system. The reform programme was set up to ensure universal access to primary healthcare in Egypt and ensure its quality and equitability. “The programme entails components including service provision reform, institutional reform, human resources development reform, pharmaceutical development reform and financial reform.” Included in the financial reform is health insurance.

“Government health insurance covers around 50% of the population”, he said. To make up the shortfall he said the government had initiated the Family Health Fund which is funded by the government and the private sector. Although the reforms are still being implemented it is hoped that through this fund the poor will find access to healthcare fairer and the quality of service improved. Dr El Sayed said another challenge facing the MoHP was good management, or the lack of it, at some hospitals. “We have a lot of hospitals. For example we have more than 4,000 primary care facilities.”

With so many facilites it was difficult to ensure that management of these facilities was up to scratch, he said. Dr Mawsouf also made this point, saying there were problems in management “for doctors, patients and case records”.

Double burden
Beside the burden of overpopulation, Egypt is faced with a double burden of disease with a high prevalence of non-communicable diseases, such as diabetes, cardiovascular disease (often, and incorrectly, associated with wealthier developed countries) and the scourge of vector-borne diseases such tuberculosis, poliomyelitis and malaria, often associated with developing countries.

            

Pulmonary tuberculosis is a major problem in the country with a remarkably high percentage of the population infected by this disease. Malaria and poliomyelitis have essentially been eradicated with only a handful of cases reported in the last few years.

The Minister of Health, Professor Dr Mohamad Awad Tag El Din, told the World Health Organisation Eastern Mediterranean Regional (WHO EMR) annual meeting in Cairo in September that Egypt had implemented most of the recommendations proposed by WHO EMR Office which included the adoption of a regional strategic framework on integrated vector management; the appointment in the ministry of a qualified focal person for vector control; the allocation of a specific budget for integrated vector management; and the establishment of a functional intersectoral mechanism for the collaboration and coordination of all sectors in the country regarding all vector-borne diseases.

The minister also noted that Egypt was “co-operating closely with Sudan with regard to control of vectorborne diseases in northern Sudan”. He said Egypt had 250 centres for the control of malaria and 2,500 centres for the control of vector-borne diseases.

            

Non-communicable diseases
The increasing incidence of non-communicable diseases (NCDs) – cardiovascular diseases, diabetes, cancer and renal, genetic and respiratory diseases – places a huge burden on Egypt’s healthcare resources. According to a 2003 report by Dr Mohamed Hassan Barakat, Epidemiology and Surveillance Unit, MoHP, 41% of all deaths in Egypt are from NCDs and this was expected to increase as the population aged.

In 2000 the government established the Epidemiology and Surveillance Unit to track the incidence of NCDs.

Following the establishment of the unit, Egypt has collaborated with the WHO for STEPwise surveillance (a coordinated programme for the standardised and sustainable surveillance of NCD risk factors) and is sharing information in EMAN (Eastern Mediterranean Approach to Non- Communicable Diseases) network. Dr Barakat said the MoHP considered NCDs a priority. He said teaching hospitals and medical institutes, such as diabetes, nutrition and cardiac institutes were ready to co-ordinate their efforts to promote surveillance.

Good reputation
Despite these difficulties, medical practice in Egypt has always enjoyed a good reputation. Modern hospitals are abundant across the country, both in governmental and private sectors.

Numerous physicians graduating from Egyptian faculties of medicine with a high standard of medical knowledge. Students from many Arab countries and Africa come to study medicine in Egypt. One of Egypt’s claims to fame in the medical world is Sir Magdy Yacoub, the renown cardiac surgeon who graduated from Cairo University. Sir Magdy was the first non-British physician to be knighted by the Queen of England.