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No Hospitals for the Poor:

How 20,000 Beds Disappeared from Egyptian hospitals

Muhammad hammed

07/11/2020

In mid-May, Basma Issam felt a high temperature and shortness of breath. Within two days, her family members complained of the same symptoms. At 24 years old, Basma lives in an apartment in a suburb east of Cairo with her mother, sister, husband, her nursing baby daughter and her grandmother.

Two days after the symptoms appeared, she went to a private hospital for a chest CT scan. “At that point it was confirmed that my family and I were positive for COVID-19,” Basma told the reporter.

By July 13, 2020, the number of recorded COVID-19 cases in Egypt had reached 82,000. Since the announcement of the first case in mid-February, 3,858 died from the virus.

After her diagnosis, Basma tried to find a place for her family in a quarantine hospital, but due to its overcrowdedness, had to resort to home quarantine. Basma’s family is not alone in being forced to home quarantine –– the ARIJ investigator documented 10 other families similar to Basma’s that were unable to secure beds in government hospitals.

Between 2005 and 2019, the number of government hospitals in Egypt decreased by 17.6%; from 1,167 beds to a mere 691. Conversely, the number of private sector hospitals increased from 652 to 1,157, marking 77.4% rise, as reported in the health bulletin issued by the Central Agency for Public Mobilization and Statistics in 2019.

This investigation documents how the Egyptian government made a series of decisions that closed 476 government hospitals and ousted 60 infection hospitals –– what have been termed the “hospitals of the poor”. This happened at the end of the 1990s with the health reform plan, in which infection hospitals were transformed into mere departments of central hospitals.

This decrease has left thousands of Egyptians unable to access adequate health care during the COVID-19 pandemic. Exacerbating the situation is the successive increase in the cost of treatment, and a rise in the poverty rate to 32.5%, as reported in the income and spending statement issued by the Central Agency for Public Mobilization and Statistics for 2019.

Egypt bottoms the world’s healthcare index ranking, and ranked 84th out of 89 countries in terms of the level of healthcare provided to its citizens, according to 2019 data from CEOWORLD Healthcare Magazine.

A rise in the number of private hospitals and a decline in the number of government hospitals
hospital icon

Number of hospitals - Governmental sector

2005

1167

2018

691

minus icon Decreased by

40.7%
hospital icon

Number of beds - Governmental sector

2005

116150

2018

95683

minus icon Decreased by

17.6%
hospital icon

the number of hospitals - Private sector

2005

652

2018

1157

plus icon Increased by

77.4%
hospital icon

Number of beds- Private sector

2005

18574

2018

35320

minus icon Increased by

90.1%

The Beginning of Privatization

Dr. Muhammad Hassan Khalil is the general coordinator of the Program to Defend the Right to Health, a health rights organisation. He attributes the decline in the number of government hospitals to the privatization programs that the government has begun to implement.

In a phone call, he said that the health reform program launched by the Ministry of Health in cooperation with the World Bank in 1998 included the transformation of health services to become “profitable”, instead of being available at cost.

Khalil added that Dr. Hatim Al-Jabali’s tenure at the Ministry of Health from 2005 to 2011 marked a crucial step in privatization. It started with the attempt to privatize health insurance services in 2006 and continued with decision No. 637 to establish the Egyptian Healthcare Holding Company in the ensuing year.

Khalil explained that if it had not been for the court ruling issued in 2008 to stop the establishment of this company, the Egyptian health insurance assets would have been sold. After these plans were aborted, the government focused on another aspect of privatization by closing about 70 infection hospitals in February 2008.

This is in addition to the closure of about 500 “Takamol”, or integrated hospitals, established by the former Minister of Health, Ismail Salam, to serve as a link between primary health units and central hospitals. This is all under the pretext of low occupancy rates –– less than 25% –– and the lack of financial allocations. According to Khalil, this is one of the reasons for Egypt's suffering during the COVID-19 pandemic.

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The Unified List of Regulations

Eight days passed in late May, and Basma Issam’s grandmother lost consciousness for more than 24 hours. During this time, Basma and her family searched relentlessly for a hospital to save her life.

After Basma gave up on finding a government ambulance, she was forced to hide her grandmother’s COVID-19 infection and contacted a private ambulance. However, when they saw her grandmother’s condition, they refused to take her down from her fourth floor apartment. Basma’s family was forced to carry this burden alone.

“I didn't know what to do or where to go with my grandmother,” Basma says. She decided to go to the Health Insurance Hospital in Naser City –– the closest to her family –– after it was dedicated to COVID-19 patients. However, because she arrived in a private ambulance, the hospital’s security officers refused to receive her grandmother.

Since 2010, management of Egyptian hospitals has changed. The Minister of Health, Hatim Al-Jabali, issued regulation No. 674 known as the “Unified List,” under which Egyptian hospitals were divided into six categories for the first time with a specified number of beds. This was unlike the previous regulation, No. 239 issued in 1997, which did not limit the number of beds in a single hospital.

According to the list, obtained by ARIJ, the first category includes public hospitals located in capitals of governorates, or in administrative centers with populations exceeding 500,000 people. The clinical capacity of the first category was set at 200 beds or more. The second category includes central hospitals of type “A”, serving administrative centers whose population ranges between 100,000 to 500,000 people. The second category names a capacity of 100 to 199 beds.

The third category includes the central hospitals of type “B”. These are located in cities with less than 100,000 inhabitants, with a clinical capacity ranging from 50 to 99 beds. The fourth category covers “quality hospitals” that serve cities also with populations less than 100,000, with the number of beds ranging from 50 to 99.

The fifth and sixth categories are the first and second models of health facilities. These provide primary care and family health services, and are the first point of contact for citizens. These facilities provide 1,000 to 20,000 beds. Once this regulation was implemented, about 60 infection hospitals went out of service as they turned into internal departments of central hospitals. Unfortunately, most of the infection hospitals are located in poor cities and villages; therefore, their affiliation with the central hospitals was changed from category “B,” leading to the elimination of around 5,235 beds.

ARIJ found, by reviewing the annual health bulletin issued by the Central Agency for Public Mobilization and Statistics from 2005 to 2019, that the number of beds in infection hospitals decreased from 9,904 in 2005 to 4,669 beds in 2019 –– marking a 50% drop.

Data of 60 infection hospitals that were converted into departments in Egypt

Lower Egypt

pin icon Al Qalyubia
pin icon El Beheira
pin icon Al Sharqiya
pin icon Dakahlia
pin icon Menofia
pin icon Kafr El Sheikh
pin icon Damietta
pin icon

The hospital closed in 2010

Bahteim Hospital

pin icon

The hospital closed in 2010

Kharkania Hospital

pin icon

The hospital closed in 2010

Shebin El-Qanater Hospital:

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The hospital closed in 2010

El Qanater Hospital

pin icon

The hospital closed in 2010

Al-Khanka Hospital

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The hospital was transformed in 2009

Delengat Hospital

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Partial hospital closure in 2010

Al-Matamir Hospital

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Shoubrakhit Hospital:

The hospital turned into a department of Shoubrakhit Central Hospital.

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Kom Hamada Hospital:

The number of beds has been reduced

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Rashid Hospital:

The number of beds has been reduced

pin icon

Tahrir Hospital:

The number of beds has been reduced

pin icon

Itay Al-Baroud Hospital:

The number of beds has been reduced

pin icon

Minya Al-Qamh Hospital:

The number of beds has been reduced

pin icon

Belbeis Hospital:

The number of beds has been reduced

pin icon

Husseinieh Hospital:

The number of beds has been reduced

pin icon

Ibrahimia Hospital:

The number of beds has been reduced

pin icon

Hehia Hospital:

The number of beds has been reduced

pin icon

The building has been worn out since 2010

Dikirnis Hospital

pin icon

Manzala Hospital

The number of beds has been reduced

pin icon

Mit Ghamr Hospital

The number of beds has been reduced

pin icon

Shoubrahor Hospital

The number of beds has been reduced

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Sherbin Hospital:

The number of beds has been reduced

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Belqas Hospital:

The number of beds has been reduced

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The hospital closed in 2010

Sadat Hospital

pin icon

مستشفى زاوية الناعورة:

The number of beds has been reduced

pin icon

مستشفى تلا:

The number of beds has been reduced

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Bella Hospital:

The number of beds has been reduced

pin icon

Motobas Hospital:

The number of beds has been reduced

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Zarqa Hospital:

The number of beds has been reduced

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Faraskur Hospital:

The number of beds has been reduced

Upper Egypt

pin icon Beni Suef
pin icon Giza
pin icon Minya
pin icon Asyut
pin icon Sohag
pin icon Qena
pin icon Aswan
pin icon Ismailia
pin icon Luxor
pin icon

It was transferred to a department of Al Wasiti Central Hospital in 2010

Grade Hospital: The number of beds has been reduced

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A decision was issued to remove it in 2002 due to the building's wear and tear.

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Al-Ayyat Hospital:

The number of beds has been reduced

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Al Fashn Hospitals: The number of beds has been reduced

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And it turned into a department of Al-Saf Central Hospital A in 2010

The number of beds has been reduced

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Atfih Hospital:

The number of beds has been reduced

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Al-Ayyat Hospital:

The number of beds has been reduced

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Transferred to a department of Al-Fikriyah Central Hospital A in 2010.

The number of beds has been reduced

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Transferred to a department of Dairout General Hospital in 2010.

The number of beds has been reduced

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The number of beds has been reduced

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Abu Tig Hospital: The number of beds has been reduced

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Al-Ghanayem Hospital: The number of beds has been reduced

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Al-Badari Hospital: The number of beds has been reduced

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Dweir Hospital: The number of beds has been reduced

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Transferred to a department of Gerga General Hospital in 2010.

The number of beds has been reduced

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Tama Hospital: The number of beds has been reduced

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Facility Hospital: The number of beds has been reduced

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Akhmim Hospital: The number of beds has been reduced

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Juhayna Hospital: The number of beds has been reduced

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Belina Hospital: The number of beds has been reduced

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Maragha Hospital: The number of beds has been reduced

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Transferred to a department of Deshna Central Hospital A in 2010.

The number of beds has been reduced

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Farshout Hospital: The number of beds has been reduced

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Naqada Hospital: The number of beds has been reduced

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Endowment Hospital: The number of beds has been reduced

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Qeft Hospital: The number of beds has been reduced

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Transferred to a department of Drau Central Hospital in 2010.

Drew Hospital: The number of beds has been reduced

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The hospital was transferred to a department affiliated with Nasr El Nuba Central Hospital in 2010

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Transferred to a department of Esna Central Hospital in 2010.

Esna Hospital: The number of beds has been reduced

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Al-Qassaseen Fever Hospital: The hospital was closed and turned into a department inside Al-Qassasin Central Hospital B.

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And it's still closed

Al-Tal Al-Kabeer Fever Hospital: Its construction cost about 31 million pounds since 2005

Moreover, the unified list made no mention of integrated hospitals, which contrasts the 1997 regulation which defined these hospitals as those run by a doctor who had previously worked in health services, had a qualification higher than a bachelor’s degree, and was to be assisted by a sufficient number of doctors and technicians needed to perform medical and preventive services.

According to the report issued by the Ministry of Health in 2012, of which ARIJ obtained a copy, the number of “Takamol” or integrated hospitals in all governorates had reached 522. In 2016, the Ministry of Health was preparing to launch these in a partnership system with the private sector based on a suggestion from the former Minister of Health, Ahmad Imad.

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Crisis in Hospital Beds

Time passed slowly in front of the Health Insurance Hospital in Naser City. Basma spent it yelling at the security officers, begging them, “By the mercy of the Prophet, please put her on an oxygen machine, even if on a chair!”

Her attempts failed against the obstinance of the iron gate.

Due to the 2010 regulation, the number of public hospital beds decreased from 116,100 beds in 2005 to 95,700 beds in 2019. Reviews conducted on this data issued by the annual health bulletin of the Central Agency for Public Mobilization and Statistics, revealed that 20,500 beds had been eliminated.

In March 2011, the Minister of Health, Dr. Ashraf Hatim, issued decision No. 344 to suspend the implementation of the 2011 unified list. This came after the toppling of the regime of former President Hosni Mubarak (1981-2011) following the January revolution. Even then, Hatim did not reinstall the beds.

Hatim, now the former Minister of Health, explained that his decision to suspend the unified list was based on recommendations by a committee that included lung infection specialists.

In a phone call, he said the committee concluded that, in order to protect the country from epidemics and infectious diseases like bird flu or COVID-19, hospitals dedicated to infectious diseases must be preserved. The committee recommended that they be developed in anticipation of current and future pandemics.

Hatim says that a plan for development was set, but the country’s political conditions at the time prevented it from being executed. The plan remains neglected until now.

North Sinai
The number of beds
2005
52
The number of beds
2008
0
The size of the shortage in the number of beds
bed icon
52
South Sinai
The number of beds
2005
0
The number of beds
2008
110
The size of the shortage in the number of beds
bed icon
110
Red Sea
The number of beds
2005
40
The number of beds
2008
34
The size of the shortage in the number of beds
bed icon
6
Aswan
The number of beds
2005
305
The number of beds
2008
93
The size of the shortage in the number of beds
bed icon
212
New Valley
The number of beds
2005
103
The number of beds
2008
31
The size of the shortage in the number of beds
bed icon
72
Luxor
The number of beds
2005
70
The number of beds
2008
25
The size of the shortage in the number of beds
bed icon
45
Luxor
The number of beds
2005
70
The number of beds
2008
25
The size of the shortage in the number of beds
bed icon
45
Qena
The number of beds
2005
486
The number of beds
2008
151
The size of the shortage in the number of beds
bed icon
355
Sohag
The number of beds
2005
497
The number of beds
2008
336
The size of the shortage in the number of beds
bed icon
161
Asyut
The number of beds
2005
681
The number of beds
2008
402
The size of the shortage in the number of beds
bed icon
279
Minya
The number of beds
2005
677
The number of beds
2008
345
The size of the shortage in the number of beds
bed icon
332
Giza
The number of beds
2005
955
The number of beds
2008
0
The size of the shortage in the number of beds
bed icon
995
Beni Suef
The number of beds
2005
195
The number of beds
2008
67
The size of the shortage in the number of beds
bed icon
92
Suez
The number of beds
2005
230
The number of beds
2008
95
The size of the shortage in the number of beds
bed icon
135
Cairo
The number of beds
2005
1215
The number of beds
2008
378
The size of the shortage in the number of beds
bed icon
837
Ismailia
The number of beds
2005
407
The number of beds
2008
150
The size of the shortage in the number of beds
bed icon
257
Al Sharqiya
The number of beds
2005
376
The number of beds
2008
127
The size of the shortage in the number of beds
bed icon
249
Damietta
The number of beds
2005
243
The number of beds
2008
198
The size of the shortage in the number of beds
bed icon
45
Dakahlia
The number of beds
2005
321
The number of beds
2008
66
The size of the shortage in the number of beds
bed icon
255
Kafr El Sheikh
The number of beds
2005
168
The number of beds
2008
266
The size of the shortage in the number of beds
bed icon
-98
El Beheira
The number of beds
2005
490
The number of beds
2008
191
The size of the shortage in the number of beds
bed icon
299
Alexandria
The number of beds
2005
451
The number of beds
2008
265
The size of the shortage in the number of beds
bed icon
186
مطروح
The number of beds
2005
51
The number of beds
2008
25
The size of the shortage in the number of beds
bed icon
26
Al Qalyubia
The number of beds
2005
499
The number of beds
2008
200
The size of the shortage in the number of beds
bed icon
299
Menofia
The number of beds
2005
452
The number of beds
2008
516
The size of the shortage in the number of beds
bed icon
-64
Gharbia
The number of beds
2005
626
The number of beds
2008
428
The size of the shortage in the number of beds
bed icon
198

Moreover, Dr. Tarek Kamel, former secretary general of the Medical Syndicate Fund, confirms that Egypt suffers from a shortage in beds in government hospitals compared to global population percentages.

In a phone conversation, he attributed the reasons to the lack of financial capabilities. He explained, “80% of health services are about financial capabilities, and only 20% are about good management and recruitment.”

It is noteworthy that the budget allocated to the Ministry of Health did not reach 3% of Egypt’s gross national product, as it is entitled to in the 2014 Constitution. In fact, reviews of the Ministry of Health budgets for the past four years reveal that this percentage did not exceed 1.6% of the gross national product.

The size of the Ministry of Health budget
The average number of beds in Egypt dropped from 22 beds per 10,000 people in 2005 to only 5.2 beds in 2011 before gradually increasing to 13.5 beds in 2019, according to data issued by the World Health Organization in 2020. health bulletin data issued by the Central Agency for Public Mobilization and statistics in 2019 show that the average, as the World Health Organization recommends that the number of beds ranges between 3 to 5 beds per 1000 individuals. The total number of beds in Egypt is 131,030, while this number should range between 300,000 and 500,000 beds, according to recommendations of the World Health Organization.
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Infection Hospitals: The First Line of Defense

After an hour of crying and begging, Basma took her grandmother to the Abbassia Fever Hospital, but the security officers intercepted her again. She explained that she contacted “everyone and anyone I know, until my grandmother was admitted to the hospital after much agony.”

Finally, more than 24 hours after Basma’s grandmother lost consciousness, they found her an empty chair in the corner of the hospital’s crowded reception hall.

The Egyptian Institute for Studies defines infection hospitals as the “first line of defense” to address infectious diseases and epidemics, including the Coronavirus. These hospitals could be fully dedicated to quarantine COVID-19 patients.

A study published by the Institute last March states that infection hospitals suffer from a shortage in equipment, rendering them unable to receive COVID-19 patients. The Ministry of Health had designated about 370 quarantine hospitals, none of which include the 60 infection hospitals that were turned into departments.

The Institute explains that infection hospitals suffer from an “identity crisis,” due to the fluctuation of their affiliation between the curative and preventive medicine sectors in the Ministry of Health. This caused an imbalance in their structure in 2011, in which administrative responsibilities were relegated to the preventive sector and technical responsibilities to the curative sector. In 2017, the management of infection hospitals was fully transferred to the preventive sector.

It is noteworthy that the decision to transfer these hospitals to the preventive sector led to a delay in joining the comprehensive health insurance system. This affected the future of these hospitals, leaving them out of the priority lists of development and efficiency enhancement programs.

the Ministry of health is divided administratively into 10 sectors: the sector of the minister's office; the Human Resources and Sustainable Development sector; the Primary Healthcare sector; the Preventive Affairs and Endemic Diseases sector; Affiliated Bodies; the Population and Family Planning sector; the Regional Health Affairs sector; the Strategic Planning and Follow-up sector; the Therapeutic Care sector; the General Secretariat sector for Financial and Administrative Affairs"

Dr. Tarek Ali, deputy director of the Abbassia Fever Hospital, says that doctors of infectious diseases are of those most vulnerable to infection because of the nature of their work in handling epidemics and operating in quarantined areas. However, their “infection allowance” ranges between 19 to 30 pounds, depending on the doctor's rank.



After a legislative amendment, President Abdel Fattah Al-Sisi decided to increase the risk allowances of medical professionals by 75%, from the current value to 1225 pounds per doctor. The Egyptian Medical Syndicate, however, states that the net increase in the allowance after deductions would only range between 250 to 400 pounds.

In a phone call, Dr. Tarek Ali said that the limited salaries of doctors in infection departments, and the difficulty of registering their affiliation within the ministry, led to a reluctance on behalf of medical school graduates to enter the department.



Egypt suffers from a general shortage in its numbers of doctors; out of 212,835 physicians who have obtained a license to practice the profession in the Egyptian Medical Syndicate, only 82,000 –– 38% –– work. According to a study prepared by the Supreme Council of Universities and the Technical Office of the Egyptian Ministry of Health, those that work either work in Ministry of Health-affiliated hospitals, university hospitals or in the private sector.

The study issued in 2019 shows that 62% of doctors work outside Egypt, have resigned from government work or obtained leave from the government. This data confirms that the true rate of doctors in Egypt is one doctor for every 1,162 individuals. The global average is one doctor per 434 individuals.

the number of doctors per 10 thousand individuals in Egyptian governorates
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The Poor Continue to Suffer

Once Basma’s grandmother settled on one of the reception chairs of Abbassia Hospital, the nurse put a respirator mask on her. In the meantime, Basma bought a comforter and a blanket to keep her warm.

While Basma was submitting her information and phone number, she was surprised that the medical staff asked her to leave, claiming that the hospital only accommodates patients.

A study conducted by researchers from the University of Queensland in Australia in partnership with the Egyptian Ministry of Health shows that a reduction of health expenditures has forced citizens to increase their personal spending on treatment. This, in turn, led to inequality in accessing healthcare, leaving it only to those who can afford it.

The study, issued in 2018, adds that the economic policies of the two former presidents, Anwar Sadat (1970-1981) and Hosni Mubarak (1981-2011), led to the privatization of the healthcare system.

A report issued by the 20/20 Cooperation Agreement for Health Systems funded by the United States Agency for International Development (USAID) shows that personal spending on health in Egypt increased from 51% in 1995 to 60% in 2008. The World Health organization (WHO), however, has estimated the latter percentage at 72%.

The report divides personal spending methods into nine areas: private clinics at 38.4%; followed by pharmacies at 33%; private hospitals by 8.2%; hospitals of the Ministry of Health by 3.5%; treatment centers at 2.9%; university hospitals at 2.8%; health insurance hospitals at 1.9%; then 0.9% over other public hospitals; and finally, 8.3% for other expenses.

The 2010 report recommends increasing public investment in the health sector and addressing the issue of out-of-pocket spending. It also considers continued out-of-pocket spending a heavy burden, and a matter of grave concern.

It calls to address the lack of efficiency in the current system by merging strategy and procedure into a single system. This should be designed to cover various population groups, and to link investments to disease burden and demographic trends. Currently, investments in health do not reflect the geographical distribution of disease burden –– whether caused by increasing rates of chronic diseases, or a rise in the demographic of seniors.

Ten minutes after Basma left the Abbassia Fever Hospital, the receptionist called her to inform her of her grandmother’s death.

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