Egypt’s health system problems laid bare

“Unless you have inherited your father’s medical practice, moving abroad, especially to the Arab Gulf states, is an absolute no-brainer,” says Ameer, which is not his real name. Like the other doctor interviewed for this article, he asked that his name not be used so he could speak freely about an issue the Egyptian government deems sensitive¹ . Already, many of Ameer’s 2013 cohort are practicing doctors in the Arab Gulf states and Europe, he says.

But while the trend of Egyptian physicians moving abroad in large numbers has not escaped notice² , it rarely commanded national attention until the arrival of the coronavirus.  

COVID-19 laid bare a surprising weakness in Egypt. The country that surpasses every other in the Arab region in population size, and is among the region’s most prolific in medical schools³ , has one of the region’s lowest ratios of physicians per capita.

In the most recent data from the World Health Organization⁴ , Egypt had 445,000 physicians working in the country in 2018, nearly five doctors for every 10,000 citizens. That ratio is low by regional standards. Compare that, for instance, with 26 physicians per 10,000 people in Saudi Arabia, 23 in Jordan, seven in Iraq and Morocco, and 17 in Turkey.

Egypt has one of the region’s lowest ratios of physicians per capita.

Equally concerning about Egypt’s 2018 data is the trend. After rising between 2003 and 2014, to peak at 11 doctors per 10,000 people, the average plummeted to around eight over the following three years, and further down again in 2018. From a regional perspective, Egypt was an anomaly. In all the other countries cited above, the ratios largely steadied or improved over the same period. 

The irony is that some of those other countries, such as Saudi Arabia, appear to attain their ratios by luring Egyptian physicians.  

The reason may seem straightforward: “Working in Saudi Arabia for a year can earn you nearly as much as you would in Egypt in 30 years,” explains Ameer. 

But it is not only about good pay. At the going rates in Egypt for junior doctors, many must shuttle, in the course of one day, between two or three clinics to make a living. That means scarce attention for each patient, fatigue, and little if any time for studies and career development. 

“Only recently have I come to understand the concept of a weekend,” says Sharif, an Egyptian assistant professor in dentistry who now practices at a hospital in Saudi Arabia. With the option of eight-hour workdays, a luxury he never had in Cairo, he can now work on acquiring new digital design and 3D printing skills in his fast-changing field. 

The Gulf states are not the only countries beckoning Egyptian doctors. Over the last several years, European countries hit by their own dwindling physician numbers⁵  have endeavoured to recruit more foreign doctors^6,7 . 

These trends may partly explain the drop in Egypt’s physicians-per-capita ratio after 2014. They also illustrate something more profound. The market for medical practitioners is a global one. Doctors everywhere, including Egyptians, now factor the “Saudi option” against the UK and Swedish ones into their thinking about their careers.  

As a result, even though Egypt graduates about 7,000 new physicians annually ⁸, it only has 213,000 physicians registered as practitioners, according to a widely cited study by Egypt’s health ministry⁹. Of those registered, the study noted, only two fifths, or 82,000, actually practice in the country. But even these very low figures still do not capture the full picture. Cairo gets the lion’s share of Egypt’s doctors, starving other governorates, especially those farthest from the capital¹⁰ .

The pandemic was going to be difficult enough for this vulnerable health system. Its impact has worsened for doctors, however, by government actions and statements from officials, and a lack of personal protective equipment (PPE) for front-line physicians. 

As coronavirus-related fatalities grew among physicians, exceeding 90 as of June 26¹¹ , relations between the Egyptian Medical Syndicate and the government soured. The prime minister suggested in a statement that the blame for Egypt’s growing coronavirus deaths, hovering in the high 80s in the last week of June according to official numbers, falls on doctors not showing up for their shifts. The syndicate condemned the remarks, warning they might incite violence against doctors¹² .

The remarks prompted broad discussions in media outlets and social media about the roots of the health system’s longstanding ailments. One was the government’s failure to comply with the constitutional stipulation that at least 3% of the country’s gross domestic product (GDP) be allocated to the healthcare system and for that percentage to rise gradually to match global averages. In the 2020-21 budget approved in April, 3.65% of the country’s GDP encompasses spending on health, pre-college and higher education, and scientific research, instead of the 10% mandated by the constitution¹³ .  

Safety is an enduring problem for doctors.

Amr El Shobaki, a political scientist and politician, rejected in a Facebook post¹⁴  the “shocking” statement from the prime minister, noting that “the real reason [for the rising death rate] is the health system’s low capacity, thanks to the state’s inability to furnish the minimum resources for it required by the constitution.”

Another enduring problem is safety for doctors. Tolerance of violence against doctors has not been a rare occurrence in Egypt’s emergency rooms. For years doctors have pleaded for a legislative remedy¹⁵. With the coronavirus, the violence problem got worse—and more visible. Now calls for legislation with harsher punishment for violence against medical staff are receiving wider attention and support.  

In this regard, too, Egypt trails other Arab countries. In May, Sudan passed legislation that toughens penalties for violence against medical staff¹⁶. In Saudi Arabia, transgressions against medical workers can lead to 10 years in prison and a million Saudi riyals (US$274,000) in fines¹⁷.

Sharif, the assistant professor in Saudi Arabia, finds the delay in enacting similar laws in Egypt incomprehensible. It adds to the general sense among doctors “who are often overworked and underpaid, that they are thoroughly underappreciated by society; so much so that violence against them is OK,” he says.

Given disaffection among doctors with the state of their profession, it is surprising that so many young Egyptians continue to pursue careers in medicine. Ameer, the young physician from Cairo, sometimes regrets going to medical school. “I told my younger cousins not to repeat my mistake,” he says. But they have not heeded his warning. “They responded the way I did when I got similar advice: they didn’t listen.” That is reason for hope.

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