From reform to excellence: the future of health care in Egypt
Authors: Ahmed El-Sobky, Mazen Aladdin
Journal: The Lancet Global Health (2024)

Despite being at the midpoint of the Sustainable Development Goals, the world finds itself far from achieving many of its health-related targets. None of the 53 health-related indicators tracked by WHO1WHOWorld health statistics 2024: monitoring health for the Sustainable Development Goals.https://www.who.int/publications/i/item/9789240094703Date: 2024Date accessed: June 20, 2024Google Scholar have been fully achieved, and current trends suggest that none are on track to be met. Egypt's health-care reforms provide a relevant case study in this context, offering insights into how a lower-middle-income country can strive toward universal health coverage (UHC) while facing substantial obstacles. WHO defines UHC as ensuring that "all people have access to the full range of quality health services they need, when and where they need them, without financial hardship".2WHOUniversal health coverage.https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)Date: 2024Date accessed: June 18, 2024Google Scholar Its definition "covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across a person's life course".2WHOUniversal health coverage.https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)Date: 2024Date accessed: June 18, 2024Google Scholar As with many countries globally, Egypt considers health care to be a fundamental right, enshrined in the 2014 Constitution3Supreme Standing Committee for Human RightsThe Egyptian Constitution.https://sschr.gov.eg/en/the-egyptian-constitution/Date: 2014Date accessed: June 23, 2024Google Scholar that affirmed that every citizen has the right to health and comprehensive health care in accordance with quality standards. The Constitution also committed to establishing a universal health insurance (UHI) system3Supreme Standing Committee for Human RightsThe Egyptian Constitution.https://sschr.gov.eg/en/the-egyptian-constitution/Date: 2014Date accessed: June 23, 2024Google Scholar for all Egyptians. WHO offers a guiding framework to assist countries in this endeavour, often represented as a cube,4WHOHealth systems performance assessment.https://www.who.int/publications/i/item/9789240042476Date: 2022Date accessed: July 1, 2024Google Scholar which encompasses three pivotal dimensions crucial for UHC: expanding priority services, including more people, and reducing out-of-pocket payments.5The Hieroglyphs of HealthGlobal health series: the path to universal health coverage.https://thehieroglyphsofhealth.blogspot.com/2024/04/global-health-series-path-to-universal.htmlDate: 2024Date accessed: June 28, 2024Google Scholar To include more people and introduce more services to be covered, Egypt has adopted a few attempts to reform the health-care system. The late 1990s heralded the start of an ambitious health sector reform programme, which was followed by another attempt in the early 2000s. Both sought to create a seamless continuum of care that integrated family health units with advanced medical facilities, including district hospitals, specialised centres, and teaching hospitals, aiming to provide holistic health care across the community.6United States Agency for International DevelopmentHealth Sector Reform Program (HSRP) in Egypt: evaluation report.https://pdf.usaid.gov/pdf_docs/pnadg021.pdfDate accessed: July 22, 2024Google Scholar Although Egypt has made substantial attempts to improve health outcomes, disparities remain. According to the World Bank's Open Data, between 1990 and 2017, Egypt's maternal mortality ratio declined from 106 to 37 deaths per 100 000 livebirths and the infant mortality rate fell from 60 to 18 deaths per 1000 births.7World Bank GroupSupporting Egypt's universal health insurance system.https://projects.worldbank.org/en/projects-operations/project-detail/P172426Date: 2024Date accessed: July 23, 2024Google Scholar Life expectancy increased from 66 to 72 years over the past two decades. Egypt is also facing a growing number of non-communicable diseases. The 100 Million Healthy Lives programme8WHOEgypt becomes the first country to achieve WHO validation on the path to elimination of hepatitis C.https://www.emro.who.int/media/news/egypt-becomes-the-first-country-to-achieve-who-validation-on-the-path-to-elimination-of-hepatitis-c.htmlDate: 2024Date accessed: July 23, 2024Google Scholar, 9Haseltine WA How Did Egypt Eliminate Hepatitis C In Less Than One Year?. Forbes, May 18, 2023https://www.forbes.com/sites/williamhaseltine/2023/05/18/how-did-egypt-eliminate-hepatitis-c-in-less-than-one-year/?sh=5582c94b30e9Date accessed: July 23, 2024Google Scholar showed that, of 60 million people older than 18 years and 8 million people between age 12 years and 18 years, more than 4% had antibodies for hepatitis C virus, 21% had hypertension, and about 5% tested positive for diabetes.10ACCESS Health InternationalUniversal disease screening and treatment—the Egyptian example.https://accessh.org/press/universal-disease-screening-and-treatment-the-egyptian-example/Date accessed: July 22, 2024Google Scholar Counselling is under way for the 40% of the screened population that are considered to be people with obesity by WHO standards. The momentum of health-care reform in Egypt peaked in 2018, and with a vision to ensure health for all, Egypt embraced a transformative path towards UHC with the enactment of the UHI system. The UHI law, also known as Law Number Two of 2018,11State Information ServiceUniversal health insurance law number 2.https://beta.sis.gov.eg/en/egypt/society/health-care/universal-health-insurance-law-no-2-of-2018/#:~:text=Comprehensive%20health%20insurance%20is%20a,accordance%20with%20the%20exemption%20controlsDate: 2018Date accessed: July 10, 2024Google Scholar is a cornerstone of this transformation, aligning with the sustainable development vision of Egypt 2030 and the UN Sustainable Development Goals, particularly Goal 3.12Ministry of Planning and Economic DevelopmentEgypt's Vision 2030.https://mped.gov.eg/DynamicPage?id=115&lang=en&Egypt-Vision-2030Date: 2020Date accessed: July 23, 2024Google Scholar The UHI law also reinforces the constitutional mandate for quality health care, ensuring comprehensive coverage for all Egyptians, with substantial government subsidies for approximately 30% of the population who are the most vulnerable to health disparities. The implementation of the UHI system has been orchestrated by three newly established entities. The UHI authority is the purchaser of the service, the Egypt Healthcare Authority is the main medical service provider, and the General Authority for Healthcare Accreditation and Regulation is the national accreditor. These agencies ensure that the roll out of the UHI system is synchronised and effective, with the Egypt Healthcare Authority managing health-care provision and the General Authority for Healthcare Accreditation and Regulation setting stringent quality benchmarks. During the initial stages of UHI implementation in Egypt, out-of-pocket payments decreased, dropping from 62·7% of health expenditure in 2018–19 to 59·3% in 2019–20,13WHOEgypt national health accounts: establishing an expenditure baseline to support Egypt's health care reform.https://applications.emro.who.int/docs/9789292741549-eng.pdfDate: 2023Date accessed: July 22, 2024Google Scholar indicating improved financial protection. However, attributing this entirely to the UHI roll out is challenging. Current health-care expenditure growth has been stable in real terms but has lagged behind economic growth since 2017. From 2010 to 2017, current health-care expenditure growth outpaced economic growth, but it has declined in relative terms to gross domestic product since 2017. Additionally, primary health-care expenditure grew by almost 20% from 2018, reaching 55·3% of current health-care expenditure in 2019–20, indicating a shift towards more primary health-care services. Central to the UHI system is the family health model, which is a system of family health units and centres that directs patients through a structured referral system to appropriate levels of care. This model is meticulously designed to serve well defined populations, and uses multidisciplinary teams to ensure comprehensive care coverage through a predefined basic benefits package while adhering to up-to-date practice guidelines. Ultimately, Egypt's journey toward UHC is a balanced act between equity, affordability, and sustainability. By redefining its approach to providing health care and upholding the principles of inclusivity and efficiency, Egypt is navigating the complexities of health-care reform to secure a prosperous and healthy future for every Egyptian citizen. The phased geographical roll out of the UHI system, which is scheduled for completion by 2032, is not only a health reform initiative but also a fundamental pillar of national development, underscoring our commitment to ensuring that every citizen benefits from high-quality, health-care services. AE-S holds a position as chairman of the Egypt Healthcare Authority, is a representative of Egypt for the UHC2030 Steering Committee, is a governing council member at the International Hospital Federation, and is a general supervisor of the Universal Health Insurance Project and the Hayah Karima Presidential initiative at the Ministry of Health and Population. MA is a general supervisor of International Development at the Egypt Healthcare Authority and is a member of the UHC2030 Task Force.