Country profiles

Egypt

Overview

Even though the total area of Egypt is about 1 001 450 km², less than 5% of the land is inhabited. The special distribution of the population presents a classic example of high metropolitan primacy. According to the 1986 census, nearly 42.4% of the total urban population lived in two of the world’s most venerable cities, Cairo and Alexandria. The total population in 1996 was 60.6 million, including an estimated 2.2 million residing abroad. The Egyptian economy, which is the second largest in the Region, has expanded steadily during past decades. In 1997, the populations below 15 years of age and above 65 years of age were estimated at 35% and 3.3%, respectively. The total adult literacy rate and the adult female literacy rate, in 1995, were estimated at 51% and 37%, respectively. The majority (94.1%) are Muslim, the remainder being Christian (Coptic). . In 1998, the crude birth rate and the crude death rate were estimated to be about 28.4 per 1000 population and 6.4 per 1000 population, respectively. Infant mortality is 25 per 1000 live births (1998). Total life expectancy was estimated at 64.7 years in 1996. Maternal mortality was 17.4 per 10 000 live births in 1993. The under-5 mortality rate was calculated to be 54.8 per 1000 live births in 1992.

Egypt has long given high priority to the provision of public health services. There has recently been an increasing emphasis on primary health care, with the adoption of new approaches emphasizing child survival interventions, the control of diarrhoeal diseases and the strengthening of rural health services. Priorities of Egyptian health policy in the 1980s included an emphasis on preventive care; a focus on the reduction of mortality and morbidity rates through prevention of childhood and endemic diseases; fertility regulation; and expansion of the national health care financing system. Egypt has declared the 1990s the "Decade for Child Protection", with specified targets and activities. The national health strategy reflects the health policy of the state. The strategy aims at providing primary health care for all of the population through a national system of health facilities at all levels (central, governorate and local). This is mainly done through free government services, health insurance and nongovernmental curative establishments.

The health system is based on primary health care, which is provided through various health establishments such as maternal and child health centres, school health units and health offices, as well as rural and urban health centres. The Ministry of Health and Population has also tried to strengthen primary health care through establishing various training centres for primary health care health teams. Attention has been focused on renovating and developing health centres and re-equipping them with new facilities. A new policy also dictates that all schools with 1000 pupils or more shall be provided with school health clinics; 80 of these clinics have already been established and 50 more are being renovated. Various health education campaigns are carried out through the health centres. In 1990 primary health care in urban areas was provided through 202 general hospitals and 1120 health centres, while in rural areas primary care was delivered through 112 district hospitals and 2582 rural health centres.

Despite the commitment to improve the coverage and services of the health care system, health care delivery in Egypt still faces some problems. Both health facilities and staff tend to be unevenly distributed, clustering in urban areas, especially in Cairo and Alexandria. For example, the average number of hospital beds per 10 000 population is 38 in Cairo and 28 in Alexandria, compared with 16 in the rest of Lower Egypt and 12 in Upper Egypt.

Health planning in Egypt takes place through the planning department in the Ministry of Health and Population, in conjunction with the various technical units in the Ministry. Similar planning units also exist in the provincial health directorates. There is a continuous process of monitoring, evaluation and follow-up in the health system. At the central level, this process is carried out by the technical department concerned in cooperation with the centre for information and documentation at the Ministry. At local level, it is carried out through technical staff, whose main duty is supervision, follow-up and evaluation in the provincial health directorates. Local communities are involved through people’s local councils at rural, urban and governorate levels (each council has a health committee) and the board of directors of general hospitals; representatives of local communities form part of the governing bodies of health centres and ambulance services. Since health plan drafts are initially prepared locally, the communities are involved in planning and finalizing these initial plans. They are also involved in the delivery and monitoring of services. The community also contributes to the financing of certain local health projects, as in the provision of land space for construction of health centres, or by paying minimal fees for services provided. People’s awareness of health problems has increased through the various public information media designed to increase their participation.

The ratio of physicians increased from 12.3 per 10 000 population in 1981 to 17.7 per 10 000 population in 1989 and 20.2 in 1995. The nursing/midwifery personnel ratio has, however, decreased from 16.5 per 10 000 population in 1981 to 23.3 in 1996 (4.7 of these working in primary health care). There were 1.3 primary health care centres per 10 000 population in 1991. The ratio of hospital beds, however, decreased from 20 beds per 10 000 population in 1981 to 20.1 in 1997, due to the increase in population without a parallel increase in hospital bedsEgypt’s national research policy is focused on priority issues. Three bodies are responsible for coordinating and encouraging research: these are the health councils, the Information Centre and the central department of research and development in the Ministry of Health and Population. The major obstacle in research, however, is shortage of funds, particularly since external funding of most of these research activities is time limited, thus hampering the continuity of research.

The Health Council, headed by the Minster of Health, is composed of representatives of all ministries and organizations that play a role in health. Lack of understanding of the seriousness of some health problems by some sectors, mainly due to lack of efficient communication, is an obstacle impeding the complete integration of intersectoral efforts.

The second five-year health plan (1993-98) re-emphasizes Egypt’s commitment to the goal of health for all by the year 2000 and to the concept and practices of primary health care. The health strategy is based on three clusters of programme: preventive care system, primary health care and curative services.

MENTAL HEALTH

Egypt was in the forefront of mental health care for many centuries. One of the earliest psychiatric hospitals was located at Cairo. It is recorded that this hospital was known for its humane treatment of the mentally ill as well as the wide range of activities for recreation and occupational therapy. During modern times, of the countries of the Region, Egypt was one of the two centres, along with Sudan, for the WHO project "Strategies for extending mental health care" (1975-81) which developed the initial programme to integrate mental health into primary health care. The national mental health programme of Egypt was developed in October 1986. A revised national mental health programme was prepared, following a review workshop in 1991. Egypt has one of the four WHO collaborating centres for mental health in the Eastern Mediterranean Region.

Mental health facilities

• Abbassiya Hospital. Abbassiya Hospital was established in 1883. It is the major psychiatric facility in the country and faces the problems that all chronic care institutions of this size face. These problems range from the negative effects of institutionalization to very low staff-patient ratio, decreasing number of doctors, old, run down buildings, and day-to-day difficulties of patients: physical health, nutrition, medication, and so on. Conditions in the hospital reached a serious level of crisis during 1995, so the director-general of mental health services has personally assumed the direct responsibility for the hospital. Since then, in spite of the fact that many basic difficulties continue, the change and improvement is quite evident.

• Khanka Hospital is located in the township of Khanka, 30 km north of Cairo. It was established 85 years ago in very large grounds and was intended to house patients and provide farms and other facilities for them to work in. Inside the hospital there are two distinct units whose special functioning is of national importance: the addiction unit and the closed ward for criminal mental patients. At present, this hospital faces many difficult conditions. One major problem here is the low doctor-patient ratio and need for incentives for personnel.

• A new hospital in Heliopolis, near Cairo Airport, is an example of a small, clean, manageable community hospital, which can function as a model for future development of mental health services in Egypt.

• Another example of this type is the Institute of Psychiatry at Ain Shams University which can function as a model for a university-based training and service delivery centre. The integrated psychiatric wards in Cairo University, Kasr El Ayni Hospital, are another example.

• Outside Cairo, the main psychiatric facility is in Alexandria. It is a 600 bed psychiatric and addiction treatment facility, built 30 years ago. It is well kept, clean and faces much fewer problems.

• Hospitals in other governorates are new and smaller in capacity.

Total facilities in the 27 governorates are:

• There are psychiatric departments and outpatient clinics in the general hospitals in 19 governorates with a total of 621 beds.

• Psychiatric departments and outpatient clinics in the nine university teaching hospitals with a bed capacity of 10-30 beds each:

- Cairo University 30

- Ayn Shams University 20

- Al Azhar University 20

- Alexandria University 30

- Tanta University 10

- Mansoura University 30

- Assiut University 10

- Zakazik University 20

- Banha University 10

TOTAL 190 beds

• Psychiatric departments and clinics for schools and university students are available in four centres in Cairo and one each in Alexandria, Qaliubiya, Tanta, Giza and Assiut. In governorates where no similar facilities are available, two days are allotted for the students in the psychiatric clinics.

• Special schools for education and rehabilitation of mentally retarded children (belonging to the Ministry of Social Welfare) are available in the following cities:

• Cairo -Four for boys and one for girls

• Alexandria -one for boys

• Tanta -one for boys

• Minya -one for boys

• Health insurance facilities. There are about 27 outpatient clinics in Cairo and Alexandria and other big cities with a few beds for the insured.

• Private psychiatric hospitals and clinics. There are seven hospitals in Cairo with a total capacity of about 760 beds.

The number of psychiatrists in Egypt is about 600 and most of them have their own private clinics, and they are all in Cairo, Alexandria or other big cities.

The following problems and future prospects in mental health services in Egypt were identified when the national mental health programme was being formulated in 1986:

• Though current mental health statistics about the whole population of Egypt are lacking, available information clearly shows the enormous prevalence of psychiatric disorders and psychosocial disturbances.

• In general, the majority of those who are in need of mental health care are unreached or are inadequately served.

• Available psychiatric facilities are rather isolated and limited to a relatively few big cities. The large mental hospitals are crowded with the chronic mentally ill (more than 75%).

This was formulated in October 1986.

The objectives of the programme are: to make essential mental health care available and accessible for all in Egypt by the year 2000 with special emphasis on the most vulnerable and inappropriately served populations; to enhance the use of mental health knowledge and skills to improve general health care; to enhance the use of mental health principles to promote social health and related functions including socioeconomic development, productivity as well as general quality of life; and to emphasize community participation as a goal as well as a means for achieving these objectives.

The strategies and approaches identified for the programme were: establishment of a national coordination group for mental health (the urgency for this action should be clearly emphasized in the newly revised mental health legislation); integration of essential mental health care into community health services starting with primary health care; extension of mental health care services involving active participation of all health personnel at all levels from specialists to primary health teams; strengthening of adequate referral services and provision of relevant modalities of treatment, as seems appropriate; promotion of appropriate use of established health record (health card) and information system; provision of essential drugs for neuropsychiatric disorders; training in mental health for health personnel at different levels for better management of mental health problems; and integration of mental health care with social services and collaboration with other related sectors in the Ministries of Education, Social Welfare, Religious Affairs, Justice and Interior, as well as with private services and nongovernmental organizations.

As part of the 1986 programme formulation, it was envisaged that the programme would include detailed activities for every biennium to improve the quality of care in the existing psychiatric services. Though the thrust of the programme would continue to be directed towards the extension of mental health care and the close integration with the general health services and related social welfare, efforts would be made to improve the quality of psychiatric care in the existing centrally located institutions.

By the end of 1995, and as described in the plan of activities, the main targets of this national programme for the extension of mental health care in 25 governorates was to be achieved. As the mental health services have already been previously extended to the Fayoum governorate, this means that by 1995, mental health services would be established in all the governorates of Egypt.

Evaluation of the previous draft mental health programme for the period 1986-90 was undertaken in 1991 by a national committee.

General achievements

The previous draft reviewed the psychosocial aspects of mental health and the simplest possible means which underdeveloped countries can use to promote it-particularly the role of human resources in sensitization and behavioural and attitudinal change. It must be noted though that owing to the very limited distribution of the draft, only partial benefit was derived from it. The draft, despite limited circulation, shed light on the value of integration of mental health services with general health services and good mental health’s role in socioeconomic development and the improvement of the quality of life. It also emphasized the importance of community participation for the promotion of mental health. It drew attention to the existing problems obstructing the provision of mental health services and the marked increase of such psychosocial problems as addiction, failure to adapt, complications arising from migration to urban areas, and so on.

Specific achievements

The general mental health administration developed a good information system that contributed positively to the smoothness and clarity of procedures. This led to the implementation of specific activities in the light of the draft plan.

Training courses were organize on mental health for general practitioners and nursing staff working at basic health care units. In 1986-87, training was provided for 250 physicians and 250 nurses in the governorates of Assiut, Minya, Gharbiya and Suez.

In 1989, training was provided for 20 trainers in Ismailiya, so that they could later train general practitioners and basic health care unit staff in their governorates (there were some constraints due to transfer of trainees, as well as to the absence of adequate systems for information, recording, referral, follow-up and evaluation).

In 1987, the Mental health care manual for primary health care physicians was published, and in 1991, the Integrated manual for basic health care units, which included a section on mental health.

The Ministry of Health and Population, having adopted the previous draft of the programme, devoted much attention to psychosocial problems, drug abuse and addiction. Sensitization symposia on drug hazards were held in the governorates of Qena, Ismailiya, Menoufiya and Marsa Matrouh. A third national conference on addiction control was held in Luxor, the same year.

In 1987, a field study was made on drug addiction and abuse covering a sample of 500 citizens. The results of the study have been published.

During the past three years, 18 new laboratories for detection of addictive substances in biological secretions have been established, covering most governorates, at a total cost of LE 2 500 000 (US$ 733 000). Training was provided for the staff of these laboratories, and fluids, reagents and other necessary supplies were also provided.

The therapeutic services offered to addicts were expanded, and special departments were established for them within mental hospitals.

State and private efforts were combined in the fields of prevention and sensitization. Hence, conferences, symposia, exhibitions and meetings were organized. Efforts centred particularly on youth meeting places such as clubs and schools. An integrated plan is being developed by the Ministry of Health and Population to reduce demand for drugs through intensive sensitization, treatment, follow-up and rehabilitation activities.

Drug addiction control activities have lately been expanded. Efforts in this direction are not confined to the Ministry of Health and Population and the Ministry of Interior, but are also shared by various other sectors. The Supreme Council for the Control of Drug Addiction and Abuse, chaired by the Prime Minister, is a leader in this direction.

Legislation for drug control has been promulgated, such as the law on drugs passed by the People’s Assembly (1989), the President’s Decree establishing the National Fund for the Control of Drug Addiction and Abuse, the joint decisions of the ministers of justice, social affairs and health establishing sanitaria and departments for the treatment of drug abuse and addiction.

Side by side with these activities, information campaigns have been intensified in the media to upgrade awareness regarding drug hazards.

According to the previous draft plan (1986-90), the improvement of mental health services was viewed as a future target to be achieved by the following plan covering the period prior to 1996. However, the Ministry of Health has allocated a sum of LE5 000 000 (US$ 1 466 000) for the development of mental health services, to fulfil the following objectives.

Support decentralization of services through establishing new mental hospitals and departments in deprived governorates to provide specialized services to citizens wherever they are. Within this context, five hospitals have been established with a total capacity of 610 beds, as follows:

• Banha Mental Hospital, Qalyiubiya Governorate (150 beds).

• Azazi Mental Hospital, Sharqiya Governorate (140 beds).

• High Dam Mental Hospital, Aswan Governorate (160 beds).

• El Tel El Kabir Mental Hospital, Ismailiya Governorate (40 beds).

• Heliopolis Mental Hospital, Cairo Governorate. (120 beds).

Helwan and Khanka mental hospitals were renovated and provided with new furniture, supplies and equipment. A new mental health department at Abassiya Hospital was inaugurated in 1991, and work is under way to develop more hospitals.

Mental health therapeutic teams are properly trained through training programmes and the Centre for Mental Health Studies.

Between 1987 and 1990, collaboration increased between the Ministry of Health and Population and the university. This was well reflected in the joint implementation of the 1988 programme by the Ministry of Health and Population, WHO and Al Azhar University (departments of mental health and community health). Within this programme, behavioural sciences were introduced to medical students.

In 1989, a workshop to support mental health activities in schools was organized in Alexandria in which physicians, administrators and teachers from schools and universities participated. As a result, training in providing school pupils with mental health care was provided to 456 teachers, school-health physicians, health visitors and school supervisors; (This activity is still continuing through local efforts in collaboration with the community health department in the faculty of medicine, University of Alexandria; Reference 73)

The contribution of the universities to community-oriented activities in the field of mental health is expanding. For example, the faculties of education and medicine at Assiut University (departments of mental health and community medicine), in collaboration with the Ministry of Health and Population, are conducting field research to assess the magnitude of mental health problems such as depression, epilepsy and mental retardation.

The High Institute of Public Health, University of Alexandria, has initiated mental health studies leading to a diploma, and masters and PhD degrees.

There has been an increase and expansion in mental health departments in the faculties of medicine. For example, Ayn Shams faculty of medicine established a mental health centre which can accommodate 100 inpatients. In 1990-91, it provided services to 850 patients at the inpatient department and 11 000 patients at the outpatient department, and in 1993 became a WHO collaborating centre for research and training in mental health.

School mental health programmes provide the best opportunity for promotion of mental health and prevention of mental disorders. In Egypt, nearly half of the population are children. The school mental health programme is an important initiative in Egypt. Since 1989, systematic efforts have been made in the governorate of Alexandria to develop a comprehensive school mental health programme. The different components of the programme are:

• a study of the prevalence and pattern of mental health problems in schoolchildren (prevalence of depression among schoolchildren was found to be 10%; anxiety among secondary-school children in their final year of was 17%).

• evaluation of existing mental health services for schoolchildren, including skills possessed by teachers and other care providers

• development of basic mental health training programmes for school social workers and teachers

• development of training programmes in mental health for the school health visitors and nurses (in-service training, undergraduate training and during the final year)

• development of basic child mental health training programmes for school health physicians

• advanced training courses for school physicians in order to develop more skills for dealing with children’s and adolescents’ problems properly

• organization of training of trainers programmes for school physicians to expand child mental health

• mental health and child development orientation for parents of preschool children

• psychosocial development orientation for adolescents and promotion of their mental health through direct meeting with them and discuss their emotional problems

• organization of special clinics for mental health care at district level to provide better services.

The programme has also developed manuals, teaching aids and health education materials to support the programme. Systematic research has focused on the impact of the training programmes in a pre-and post-training format, study of long-term sustenance of attitudes and skills and the impact of training on the attendance in school health clinics. All these studies have shown positive findings supporting the programme utility.

Between 1989 and 1997, the following training programmes were organized:

• 31 one-week training courses for 1451 school health physicians

• 24 one-week training programmes for 800 maternal child health physicians

• seven training programmes for 160 social workers at maternal child health centres

• 60 training programmes for 3055 school social workers and teachers

• two training programmes for 160 school psychologists

• Four advanced seven-week training programmes for physicians

A nongovernmental organization, the Child Mental Health Prevention Association, was established in 1995 to help spread the concept of mental health to families.

Currently, in Alexandria governorate, there are 23 guidance and counselling centres , 11 centres at maternal and child health facilities and two in paediatric hospitals. In addition, there are two centres in Kafr El Dawar, one centre in Damanhour and one centre in Marsa Matrouh governorate (Reference 73).

As a result of the above activities, mental health assessment is included as part of the general health appraisal. Twenty-four schools have been selected for model development and evaluation. Future activities envisaged are evaluation of the impact of the programme on children’s mental health in the areas of promotion, prevention and care. The other area of importance is the identification of changes at the level of families and schools towards mental health of children. It is expected that Alexandria governorate’s efforts will be replicated to the other governorates in the near future.

Unimplemented activities and main constraints were identified by the review committee in 1991. The committee reported that it was too difficult to implement the previous programme in the absence of organizational and coordinating establishments. Mental health was only partly integrated into the central training activities of the Ministry of Health and Population. It became a component of staff training programmes in urban health centres, but did not extend to rural centres, the Ministry of Health and Population, school health and pre-service training for physicians. It was not possible to prepare and develop advanced systems for information, recording, referral, follow-up and evaluation, noting that such systems are indispensable for the field implementation of the programme plan. The issues of the revision of the mental health legislation, forming a national coordination committee and the provincial coordination committees have been delayed, though it is recognized that such committees are expected to play an important role in the next stage.

The Ministry of Health and Population has made a commendable effort in implementing much of the programme components. The next plan, though, should set out to streamline all the constraints that obstructed the implementation of some of the planned activities of the previous programme. The 1991 review workshop on the national programme of mental health identified the following targets for 1991-96:

• 1991-92 - Public awareness of mental health issues through workshops and training courses.

• 1992-93 - Extension of training programmes to governorates; preparation of training materials.

Training in the various plan areas (services-research-other programmes) should be extended to cover target categories in governorates, focusing on the following governorates:

Cairo; Alexandria; Giza; Qalyiubiya; Fayoum; Ismailiya

Suez; Minya; Assiut; Aswan; Daqahliya; Gharbiya

Port Said; Bani Soueif; Sohag; Qena; Sharqiya

North Sinai; South Sinai; New Valley; Red Sea; Marsa Matrouh; Menoufiya; Kafr El Sheikh; Damietta

The Fayoum experiment

In 1974, the WHO expert committee on the organization of mental health services in developing countries recommended the development of a collaborative study on strategies for extending mental health care. In 1978, Egypt joined with other few countries from other WHO regions to conduct the proposed study. Briefly, the organization of the study entailed the selection of a pilot study area, census of health services in a selected area, survey of psychiatric morbidity of general outpatients, and assessment of the attitudes of health workers and the community towards mental disorders. The main objectives of the study were: to prevent or reduce mental morbidity and its consequences and to promote mental health care through better management and appropriate training of general health personnel and other social workers. Fayoum governorate was selected as the pilot area and Sennuris District served as the testing ground. Based on a community study, psychiatric emergencies, depression, drug dependence, epilepsy and mental retardation were selected as priority conditions to be dealt within primary health care. A training programme was organized in Fedameen rural hospital. The course consisted of two days of general orientation in mental health, followed by one week of clinical and fieldwork and discussion on the management of psychiatric problems, with due focus on the selected priority conditions. Apart from Fedameen rural hospital, Fayoum general hospital, which since 1968, has had a 13-bed psychiatric ward with a qualified psychiatrist in charge, was joined by another psychiatrist in 1976. Both remained involved in the supervision and follow-up of the training programme. Despite the inherent constraints, efforts were continued to organize training programmes for the general practitioners in the governorate. Further impetus with WHO support was given to the project in 1985, when teachers from various universities of Cairo were invited to collaborate in the training activities, and 100 physicians were taught in groups of 20. Separate courses were also held for nurses. In November 1985, the Fayoum experiment for introducing mental health services in primary health care was evaluated by WHO and a set of recommendations were made, including the continuity of the project and extension to other governorates, and its incorporation in Egypt’s national health policy and the budgetary programmes for the 1987-92 five-year plan. (WHO-EM/MENT/112. Evaluation of programme for introducing mental health into primary health care in Egypt. February 1986).

The Fayoum experiment can be summarized as follows. It made a good start in 1978 with WHO surveys and teaching in the Fedimeen rural hospital, which at that time, became the training centre for the area. The governorate’s two psychiatrists remained involved in supervision and follow-up. The effectiveness of the programme for the local population was unfortunately limited by the rapid turnover of general practitioners, many of whom complete their rural service in Fayoum only to move on to other jobs elsewhere in Egypt. The programme started to dwindle until it came to a halt in 1983. It was successfully taken up again in June 1985 by Dr Kotry with the help of World Health Organization and assisted by professors from universities in Cairo. As many general practitioners as possible were taught the practice of mental health care in one big sweep which lasted about six weeks. The governorate’s two psychiatrists provide the supervisory follow-up. After five months, the general practitioners visited were still enthusiastic, and felt confident of their aboilities. They want refresher courses, and some of them felt that, if properly instructed, they could themselves become tutors and provide some training and support to their fellow physicians, as well as to the nurses who had had training in psychiatry when in nursing school but who appear more hampered by their own cultural traditions when they were confronted with psychiatric patients. The supply of drugs did not seem to be a problem in the follow-up of the extension programme. The records kept by the physicians were adequate for statistical evaluation of their work, provided they were properly collated at the governorate health department, and analysed there or in the Ministry of Health and Population. In other words, the data were present, but the mechanisms for standardizing them further, and for analysing and presenting them in a way which permitted evaluation of the services, had still to be developed.

During 1997, as part of the Nations for Mental Health programme, the Alexandria project was initiated, covering a population of about half a million.

Two districts of the governorate of Alexandria were chosen as test and control areas. In the test area, all general practitioners and nurses in primary health care centres were trained and selected responsibilities in mental health assigned to them. A referral and back-referral system was also established between these trained personnel and Maamoura psychiatric hospital. Pre-training knowledge and attitude tests were given. The aim was to integrate mental health with the activities of primary health care centres in the test area. Five courses of training covering 170 general practitioners have been given and the project is continuing.