The World Bank recently published a report analyzing the Egyptian government’s efforts to improve socioeconomic outcomes through increased investment in human capital. While the report correctly points towards certain shortcomings such as the lack of social protection, it does not delve into the root causes of the situation.
The report begins by addressing the problem of overpopulation by referring to figures on total fertility rate and population growth rate. It highlights the challenges of malnutrition and stunting despite positive developments in other health outcomes. In 2014, nearly one in five Egyptian kids under the age of five had stunted growth. At 2.1 million, Egypt has the 12th-largest population of stunted people in the world and the most stunted children in the region of Middle East and North Africa (MENA).
Nutritional outcomes have not significantly improved between 2000 and 2014. The report recommended that Egypt should prioritize children’s nutrition to improve its human capital and achieve better health outcomes. Global nutrition strategies can make some important contribution towards that, but progress will not be achieved without more investment in social protection mechanisms.
The report presents the existing inequality between the poorest areas, mostly rural communities in Upper Egypt, and other parts of the country. Health indicators, such as the infant and newborn mortality rate, are higher in the poorest governorates. In addition to poor social determinants of health that come with living in these parts of the country, the health of these communities is also marked by a lack of public infrastructure and investment in public services.
Low health expenditure
The report shows that health sector spending in Egypt is much lower compared to international standards and has been declining in real terms. It stresses that financing of the health system, which currently relies heavily on out-of-pocket payments, needs to move toward more efficient and equitable funding sources, including higher government spending. It’s an interesting note coming from the World Bank, which otherwise aggressively promotes privatization of healthcare in every sphere. It would seem that the colossal failure of the private sector in Egypt to provide relief during the COVID-19 pandemic forced even the World Bank to tone down its support of privatization, at least at first sight.
In Egypt, only an average of 5.2% of the overall government budget, or an average of 1.5% of GDP, was allocated to the health sector between 2016 and 2021. The budget’s percentage of health expenditures fell from 5.3% in 2016 to 4.9% in 2018, the lowest in the previous five years. Government spending on health hit a historic high of 1.6% of GDP, or 6.5% of all government spending, during the height of the COVID-19 response in 2021. Now, the government is prioritizing debt, new capital, and other sectors over the health sector, which is not good news.
As a result, the main source of funding for healthcare in Egypt is out-of-pocket payments by the patients. The proportion of out-of-pocket expenses in current health spending has increased compared to previous periods, reaching 63% in 2019.
Hiding behind a technical approach
The report touches upon several important problems that healthcare in Egypt faces, but it fails to go beyond a technical analysis. For example, the report deals with the shortage of physicians as they migrate to the Gulf or to Europe because of poor salaries and working conditions. But it provides little advice on how to improve the situation.
At times, the report even puts forward contradictory advice. For example, it criticizes the absence of the private sector in primary care since the law in Egypt does not allow it. This is in contradiction to the report’s comment on the sharp rise in out-of-pocket payments that go to the private sector. By doing this, the World Bank continues to encourage the private sector in any way it can, although its own findings speak against it.
The private medical sector played a negative role during the COVID-19 pandemic, as private hospitals refused to receive many patients who could not afford to pay. Only a handful of people in Egypt were able to bear the cost of medical care in private institutions, as nearly one-third of citizens live below the poverty line. Recommendations in favor of the private sector despite such stark evidence shows a blatant lack of empathy on part of the World Bank.
World Bank ignores experiences from the ground
In the report, the World Bank chooses to ignore the underlying politico-economic reasons for the failure of the health system in Egypt. This starts with the fact that the working class in Egypt, like in many other places, does not enjoy the right to organize, form trade unions, and go on strike. There is a complete absence of organization for health workers which would help them in protesting and entering into negotiations with the government to improve their conditions. Only formal professional associations are allowed, whose representatives are chosen by the authorities. In addition, there is no room for the work of civil society organizations, nor of a press that supports social justice.
The people of this region, in addition to ongoing conflicts, political problems, and structural problems in the economy, are deprived of formal organizing and participation in public policy choices. Workers, including those in the health sector, do not have enough formalized space for organizing for change. This means that in practice they have little influence over the policies tackled by the report.
The report fails to bring a wider political critique of the problem, staying in line with a framework that doesn’t accept people’s participation in creating the social systems they want.