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Independent Report on Clinical Laboratory Testing Services Market for an Initial Public Offering (IPO) in Egypt

A Frost & Sullivan Report 2014

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Disclaimer
© November 2014 Frost & Sullivan The market research process for this study has been undertaken through detailed primary and secondary research, which involves discussing the status of the industry with leading industry participants and experts, and compiling inputs from publicly available sources, including official publications and research reports. The Expert Opinion Consensus Methodology has been used for the report. Quantitative market information is based primarily on such interviews and desk-based secondary research; therefore, making it subject to fluctuation. Frost & Sullivan has taken all reasonable care to insure that the information contained in this report is, to the best of its knowledge, in accordance with the facts and contains no omission likely to affect its import. In making any decision regarding the transaction, the recipient should conduct its own investigation and analysis of all facts and information contained in the prospectus of which this report is a part and the recipient must rely on its own examination and the terms of the transaction, as and when discussed. The recipient should not construe any of the contents in this report as advice relating to business, financial, legal, taxation or investment matters and are advised to consult their own business, financial, legal, taxation, and other advisors concerning the transaction. This Frost & Sullivan report is prepared for our client’s internal use, submission and sharing with the relevant parties as well as for inclusion in the prospectus. For information regarding permission, write to: Frost & Sullivan 210, EIB-4 BT Building Dubai Internet City Dubai, UAE

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Contents
Disclaimer ............................................................................................................................................... 2 Section I: Overview of Socioeconomic and Demographic Indicators in Egypt ........................................... 6 I. Geographical Overview ..................................................................................................................... 6 II. Population of Egypt ......................................................................................................................... 7 Population by Region ....................................................................................................................... 7 Population by Governorates ............................................................................................................ 8 Urbanisation Trend .......................................................................................................................... 8 Population by Age Group ................................................................................................................. 9 Population by Gender ...................................................................................................................... 9 III. Gross Domestic Product (GDP): Egypt ........................................................................................... 11 GDP Composition by Sector of Origin ............................................................................................. 12 Foreign Trade in Egypt ................................................................................................................... 12 Share of Main Commodity Groups Exported and Imported ............................................................ 13 IV. Gross Domestic Product Comparison ............................................................................................ 14 V. Gross Domestic Product Per Capita: Egypt ..................................................................................... 16 VI. Gross Domestic Product Per Capita Comparison ........................................................................... 17 VII. Consumer Expenditure: Egypt...................................................................................................... 19 Inflation Rates ............................................................................................................................... 19 Section 2: Overview of Egyptian Healthcare Service System................................................................... 22 I. Healthcare System Structure .......................................................................................................... 22 Public Healthcare System Structure: .............................................................................................. 22 Private Healthcare System Structure: ............................................................................................. 24 II. Healthcare Infrastructure by Level of Care ..................................................................................... 24 Quaternary / Tertiary Care: ............................................................................................................ 24 Secondary / Primary Care: ............................................................................................................. 28 III. Healthcare Expenditure: Egypt ...................................................................................................... 30 IV. Healthcare Expenditure Comparison............................................................................................. 32 V. Per Capita Healthcare Expenditure: Egypt ...................................................................................... 34 VI. Per Capita Healthcare Expenditure Comparison ............................................................................ 34 VII. Health Insurance System ............................................................................................................. 38 Section 3: Egyptian Clinical Laboratory Testing Services Market............................................................. 44

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I. Medical Laboratory Infrastructure in Egypt: .................................................................................... 44 Public Sector Infrastructure: .......................................................................................................... 44 Private Sector Infrastructure: ......................................................................................................... 46 II. Market Size – Private Independent Clinical Lab Testing Services..................................................... 47 III. Demand-side Structure and Dynamics .......................................................................................... 48 IV. Market Drivers.............................................................................................................................. 50 High Disease burden ...................................................................................................................... 50 Opportunity for Increased Usage of Laboratory Diagnostics as a Tool in Clinical Practice ............... 56 Increasing Accessibility to Lab Services: ......................................................................................... 57 Emergence of Private Participants: ................................................................................................ 57 Improving Corporate Market: ........................................................................................................ 57 Opportunity for Higher Spending Per Capita .................................................................................. 58 V. Challenges ..................................................................................................................................... 59 Lack of Quality Standards in Healthcare Organisations: .................................................................. 59 Low Density of Laboratory Health Workers .................................................................................... 59 Seasonality Effect on the Business: ................................................................................................ 60 Insurance Penetration: .................................................................................................................. 60 Heavy Dependency on Out-of-Pocket Expenditure: ........................................................................ 60 Political Instability:......................................................................................................................... 60 VI. Market Regulatory framework ...................................................................................................... 61 VII. Barriers to Entry .......................................................................................................................... 64 Definition: ............................................................................................................................................. 67 Glossary of Terms: ................................................................................................................................. 69 References: ........................................................................................................................................... 70

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Section 1: Socioeconomic and Demographic Indicators in Egypt

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Section I: Overview of Socioeconomic and Demographic Indicators in Egypt
I. Geographical Overview
Egypt is located in the North-eastern corner of Africa, with the Mediterranean Sea on its North, the Gaza Strip, Israel, and the Red Sea on its East, Sudan on its South, and Libya on its West. The country is divided into four main physical regions —the Nile Valley and Delta, the Western Desert, the Eastern Desert, and the Sinai Peninsula. Exhibit 1.1: Administrative Map of Egypt

Source: Central Agency for Public Mobilization and Statistics (CAPMAS), Egypt

The Nile Valley and Delta region in Egypt is the most important region, it covers only about 5.5 per cent (35 000 sq. km) of the total area and supports 99 per cent of the country’s population on its cultivated lands. The rich, alluvial Nile valley, which extends approximately 800 km from Aswan to the outskirts of Cairo, is also known as Upper Egypt, while the Nile Delta, which covers approximately 22,000 sq. km, is known as Lower Egypt.

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Administratively, Egypt is divided into 27 governorates (see exhibit 1.1). They are: • • • • Four city governorates (Alexandria, Cairo, Port Said, and Suez) Nine in Lower Egypt (in the Nile Delta region) Nine in Upper Egypt along the Nile River from Cairo to Aswan Five frontier governorates covering Sinai and the deserts that lie on west and east of the Nile.

II. Population of Egypt
One of the most populous countries in the Middle East, Egypt’s population has grown at a compound annual growth rate (CAGR) of 2.5 per cent between 2010 and 2013 to reach 84.6 million as per the midyear estimates published by CAPMAS, Egypt. Although, there has been improvement in control of population in the country, the overpopulation creates pressure on economic resources leading to social disparities.

Exhibit 1.2: Population, Egypt, 2010-2013
All Values in Million

CAGR: 2.5% 94.2 80.5 82.6 84.6

78.7

2010

2011

2012

2013

2019f

Source: CAPMAS-Egypt mid-year estimates-2014, 2019 data from IMF, Frost & Sullivan Analysis

According to an another estimate by the Department of Economic and Social Affairs of the United Nations on population size based on a variety of birth rate scenarios, even if Egypt succeeded in pursuing a low birth rate scenario, its population would be reaching 100 million people in 2036 and up to 105 million by 2050. At a high birth rate scenario, the population would exceed 100 million by 2025. Population by Region The top regions by population base are Nile Delta and Upper Egypt comprising 85 per cent of the total population of Egypt, followed by Cairo and Alexandria. The top regions by growth in population between 2010 and 2013 are Suez Canal, Upper Egypt, and Sinai Peninsula.
Exhibit 1.3: Population by Regions in Million, Egypt, 2010-2013 2013 % 2010 2011 2012 2013 CAGR 2010-13 Key Governorates / Areas Contribution 4.4 4.5 4.6 4.7 2.2% 5.5 Alexandria City 8.5 8.7 8.8 9.0 1.9% 10.6 Cairo City Sharkia, Dakahlia, Behera, 33.4 34.2 35.0 35.9 2.4% 42.4 Kalyoubia, Gharbia 0.5 0.5 0.6 0.6 6.3% 0.7 North Sinai

Regions Alexandria Cairo Nile Delta Sinai Peninsula

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Suez Canal Upper Egypt Others

1.6 29.4 0.9

1.6 30.1 0.9

1.7 31.0 0.9

1.7 31.8 1.0

2.0% 2.7% 3.6%

2.0 37.6 1.1

Ismailia Giza, Menia, Suhag, Asyout, Fayoum East, Northeast, and Southwest

Source: CAPMAS-Egypt-2014, Frost & Sullivan Analysis

The key cities by population are Cairo, Giza, and Sharkia with population of 9.0, 7.3, 6.2 million, respectively, and their contribution to total population as of 2013 is 10.6, 8.6, and 7.4 per cent, respectively. Population by Governorates Within the Delta region, Sharkia, Dakahlia, Behera, Kalyoubia, and Gharbia governorates contribute to 75 per cent of the total region’s population and 32 per cent Egypt’s total population. The region’s fertile soil suitable for agriculture is the reason behind its high population, which is diverse and includes fishermen from the North coast. Within Upper Egypt, which is the second most populated region, the key governorates are Giza, Menia, Suhag, Asyout, and Fayoum, which contribute to 74 per cent of the total region’s population and 28 per cent Egypt’s total population. Giza is the most populated governorate with ~23 per cent of the total population of Upper Egypt.

Exhibit 1.4: Population By Top Governorates, Egypt, 2013
All Values in million

Cairo Giza Sharkia Dakahlia Behera Menia Kalyoubia Alexandria Gharbia Suhag 6.2 5.7 5.6 4.9 4.9 4.7 4.6 4.4 7.3

9.0

Source: CAPMAS-Egypt-2014, Frost & Sullivan Analysis

Urbanisation Trend Egypt has witnessed a large shift in urbanisation in the past 50 years. According to the Central Intelligence Agency (CIA), approximately 43.5 per cent of the total population of Egypt is urbanised, as of 2011. The population of key cities in Egypt are growing fast with an annual growth rate of 1.5-1.8 per cent over the past five years. The urban population component in Egypt has increased rapidly (~4 per cent annually) than that of the total population, fuelled by diversification and industrialisation. Major cities like Cairo and Alexandria are the key destinations that the rural population of Egypt seek for migration. This has led to availability of ample workforce and labour for businesses and industries; thus enhancing the overall economy.

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However, this urbanisation in Egypt has led to many negative effects as well. The cities mentioned are built on the banks of river Nile with soil rich in nutrients and minerals and urbanisation is gradually converting this rich agricultural land in a jungle of skyscrapers and other concrete establishments. Population by Age Group As of 2013, 31 per cent of Egypt’s population comprised those in the age group of 0-15 years; the 25-30 years age group constituted 34 per cent. Between 2008 and 2013, 2.1 million people were added to the ageing population base of those above 50 years, showing a growth of 3.1 per cent. Exhibit 1.5: Population By Broad Age Groups (Years), Egypt, 2008-2013
4% 10% 33% 21% 32% 2008 0-15 15-25 4% 10% 34% 20% 31% 2010 25-50 4% 11% 34% 20% 31% 2013 Above 65

This represents the growing potential of Egypt in terms of earning capacity and economic growth. The elderly population (65+ years of age) represents 4.3 per cent of the total population. There has been an increase in the earning population in the age group 25-50 years by 3.2 per cent between 2008 and 2013 showing positive aspects for the economy. However, there has been an increase in the elderly population in the age group of 50-65 years by 3.6 per cent and above 65 years of age by 4.1 per cent. Population by Gender The male population contributes to 51 per cent of the total population.

50-65

Source: CAPMAS Egypt-2014, Frost & Sullivan Analysis

Exhibit 1.6: Age Group-wise Population, Egypt, 2013
Age Group % 15 Age Group (Years) 75+ 70--74 65--69 60--64 55--59 50--54 45--49 40--44 34 35--39 30--34 25--29 20 20--24 15--19 10--14 31 9--5 0--4 Population in Million 1.1 1.0 1.6 2.2 3.0 3.7 4.2 4.6 5.1 6.6 8.2 8.7 8.2 8.0 8.9 9.6 CAGR 2008-2013 3.9% 4.5% 4.0% 4.1% 4.0% 2.9% 2.4% 2.0% 2.7% 4.3% 3.7% 1.6% 0.3% 1.1% 3.0% 1.7%

Source: CAPMAS Egypt-2014, Frost & Sullivan Analysis

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Per Cent of Population above 65 years of Age Projections – Egypt: The ageing population base in Egypt is expected to increase in future with the contribution of population above 65 years to the total population increasing by 0.6 to 1 per cent in next 5 to 10 years.

Exhibit 1.7: Per Cent of population above 65 years age, Egypt, 2010-2025
4.2% 4.5% 4.8% 5.3%

2010

2015E

2020E

2025E

Source: Data from 2010 to 2013 from CAPMAS; total population data post 2013 from IMF and Frost & Sullivan

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III. Gross Domestic Product (GDP): Egypt
Egypt’s economy is largely dependent on petro-chemical exports to European nations. The country has healthy trade relations with African nations, the Middle East countries, and the European Union (EU) members. Egypt is a member of the Arab League and the World Trade Organization (WTO). Egypt’s economic growth has been fuelled by its significant bilateral relations with several EU nations and the United States (US). The GDP of Egypt grew steadily at a CAGR of 10.8 per cent in five years between 2008 and 2013, reaching United States Dollar (USD) 271 billion in 2013 from USD 162 billion in 2008. Going further, the GDP of the country is expected to grow at a rate of 11.8 per cent per annum to reach approximately USD 529 billion by 2019.

Exhibit 1.8: Gross Domestic Product Evolution, Egypt, 2008-2013, 2019
All Values in USD Billion

528.7

162.4

188.6

218.8

235.6

262.3

271.4

2008

2009

2010

2011

2012

2013

2019f

Source: IMF, Frost & Sullivan Analysis

Egypt has shown a higher GDP growth rate between 2008 and 2013 compared to the Levant1 countries at 6.2 per cent (excluding Palestine and Syria) and the countries under the Organisation for Economic Co-operation and Development (OECD)2 at 1.2 per cent. Countries in the Gulf Cooperation Council (GCC)3 also have a lesser combined average growth in their GDP at 6.7 per cent between 2008 and 2013. However, post 2011 there has been economic disarray due to political uncertainties and constraints that prevented the Government of Egypt (GoE), mainly constituted by the Supreme Council of the Armed Forces (SCAF), and the former president (Hosni Mubarak) from focusing on the economy. However, in late 2013, the Government committed to boost the economy by formulating an economic plan containing four main elements:
Levant countries include Cyprus, Israel, Jordan, Lebanon, Palestine and Syria. OECD countries include Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom, United States 3 GCC countries include The United Arab Emirates (UAE), The Kingdom of Saudi Arabia (KSA), The Kingdom of Bahrain (Bahrain), The State of Kuwait (Kuwait), The State of Qatar (Qatar) and The Sultanate of Oman (Oman)
2 1

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• • • •

Tackling energy and input shortages that had seriously constrained industrial production Introducing a fiscal stimulus to increase consumption and employment Increasing the minimum wage to assist low earners and, thereby, raising consumption and reducing income inequality Improving the external imbalances and building up foreign exchange reserves; thereby reducing the pressure on exchange rate

GDP Composition by Sector of Origin In the overall economy, the service sector’s contribution to the total GDP has been highest (48 per cent), followed by the industrial sector and the agriculture sector. The service sector is also the highest employment generator in the country, with approximately 47 per cent of the total labour force employed in this sector.

Exhibit 1.9: GDP Composition by Sectors, Egypt, 2013e
14.5% Agriculture 48.0% Industry

The industrial sector employs 24 per cent of the total 37.5% Services available workforce in the country. From agriculture point of view, the country has been a good producer of cotton, rice, corn, wheat, and beans amongst others. The sector Source: CIA Egypt Fact Book-2014 employs approximately 29 per cent of the total workforce present in Egypt, as of 2011. The key industries boosting the economy of Egypt are textiles, food processing, tourism, chemicals, pharmaceuticals, hydrocarbons, construction, cement, metals, and light manufactures. Foreign Trade in Egypt The Egyptian economy is dependent on foreign trade and has been one of the major contributors to world trade from the Middle East and North Africa (MENA). The Egyptian economy essentially relies on tourism, revenue from the Suez Canal, revenue from private transfers, and the export of oil and gas. Services contribute lesser as compared to goods in both exports and imports. As of 2013, WTO figures reflect that the total size of export in Egypt stood at USD 47.3 billion as compared to imports, which stood at USD 74.6 billion. Imports and exports grew by 6.6 percent and 1.6 per cent between 2009 and 2013, respectively. Exhibit 1.10: Exports and Imports in USD Billion By Goods and Services, Egypt, 2009-2013 Foreign Trade Indicators CAGR (2009-13) 2009 2010 2011 2012 2013 Imports of Goods 7.2% 44.9 52.9 58.9 69.2 59.3 Imports of Services 4.7% 12.7 12.9 13.1 15.5 15.3 Total Imports 6.6% 57.7 65.9 72.0 84.7 74.6 Exports of Goods 5.0% 23.0 26.4 30.5 29.3 28.0 Exports of Services (2.5%) 21.3 23.6 19.0 21.3 19.2 Total Exports 1.6% 44.3 50.0 49.5 50.7 47.2
Source: WTO Country Profiles’ Egypt-2014

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Exports and imports of Egypt have seen lot of changes in between 2009 and 2013. The overall percentage of change in exports and imports show a decrease between 2012 and 2013 by 12 per cent and 3 per cent, respectively. The main factor for the decrease is the recent political turmoil in the country.

Share of Main Commodity Groups Exported and Imported The manufacturing sector has been the highest contributor to the overall imports and exports in the country. The European Union and the US have been long-time partners for exports and imports mainly due to petro-chemical related products. The top products exported by Egypt are crude petroleum, petroleum gas, refined petroleum, gold, and nitrogenous fertilisers. The top products imported by Egypt are refined petroleum, wheat, crude petroleum, semi-finished iron, and petroleum gas. Exhibit 1.11: Imports and Exports in percentage by Commodity Groups and Top Countries, Egypt, 2013
Imports by Commodity Groups, Egypt, 2013

Top Countries of Import Origins, Egypt, 2013
European Union 32.0% 10.5% 7.8% 4.7% 4.6%

Manufactures Fuel and Mining Products Agricultural Products

47.7% 31.4% 18.1%

China The US Ukraine Saudi Arabia

Exports by Commodity Groups, Egypt, 2013

Top Countries as Export Destinations, Egypt, 2013
European Union India 7.4% 6.9% 6.1% 4.4% Saudi Arabia Turkey Libya 28.2%

Manufactures Fuel and Mining Products Agricultural Products

47.7% 31.4% 18.1%

Source: WTO Country Profiles’ Egypt-2014

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IV. Gross Domestic Product Comparison
The GDP at current prices4 is compared with other selected countries to understand the economic standing of Egypt (Exhibit: 1.12).

Exhibit 1.12: Gross Domestic Product Comparison, Selected Countries, 2013
All Values in USD Billion

CAGR 2008-2013 Australia Brazil Egypt India South Africa Turkey UAE Bahrain 1,505.9 2,246.0 271.4 1,876.8 350.8 820.0 402.3 32.8 748.5 175.8 77.1 202.5 21.9 290.6 33.9 45.0 11.3 65.0 16,768.1 4,898.5 3,636.0 2,807.3 2,523.2 48.0 24.9 14.6 7.4% 6.3% 10.8% 8.9% 5.1% 2.3% 5.0% 5.0% 7.6% 3.6% 5.4% 11.9% -2.8% 6.3% 9.0% 9.3% NA NA 2.6% 0.2% 0.0% -0.9% -1.4% -3.0% 0.5% -2.8%
*Values shown for Palestine and Syria are for 2012 Source: IMF-2014, Frost & Sullivan Analysis

GCC

KSA Kuwait Oman Qatar Cyprus Israel

LEVANT

Jordan Lebanon Palestine* Syria* US Japan Germany

OECD

France United Kingdom Slovenia Estonia Iceland

4

GDP at current prices is GDP at prices of the current reporting period, it is also known as the nominal GDP.

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According to International Monetary Fund (IMF) estimates, the GDP of Egypt was approximately USD 271 billion in 2013. Developed countries like the United States had a high GDP of approximately USD 16,768 billion and countries like Brazil and India had a GDP of approximately USD 2,246 billion and USD 1,876 billion, respectively. Countries in the GCC: Apart from KSA and UAE, the GDP of Egypt is better than Bahrain, Kuwait, Qatar, and Oman. Countries in the Levant: The Levant, also known as the Eastern Mediterranean, is a geographic and cultural region consisting of the “eastern Mediterranean littoral between Anatolia and Egypt”. The region currently consists of Cyprus, Israel, Jordan, Lebanon, Palestine, Syria, and part of southern Turkey. Amongst these countries, the GDP of Egypt can be compared to those of Israel, which is highest in the Levant at approximately USD 291 billion as of 2013, and Palestine Territory had the lowest GDP in the Levant. Countries in the OECD: The OECD is an international economic organisation founded in 1961 to stimulate economic progress and world trade. There are 34 countries in the OECD as of 2014 and further enlargement of the group is in progress. The countries in the OECD are:
Exhibit 1.13: Listed Countries in the OECD, 2014 Austria Belgium Canada Denmark Estonia Finland Greece Hungary Iceland Italy Japan Korea Netherlands New Zealand Norway Slovakia Slovenia Spain Turkey United Kingdom USA

Australia Czech Republic Germany Israel Mexico Portugal Switzerland

Chile France Ireland Luxembourg Poland Sweden
Source: Website of the OECD 2014

Out of these 34 countries, Australia, Turkey, and the US have already been considered for comparison in other groups of selected countries and Israel has been discussed as part of the Levant. The countries having the highest GDP in the OECD are Japan, Germany, France, and the UK with approximately USD 4,899, 3,636, 2,807 and 2,523 billion, respectively. Countries like Slovenia, Estonia, and Iceland have rank lowest in the OECD with approximate GDP of USD 48, 25, and 15 billion, respectively. As of 2013, GDP of Egypt is better than 12 countries in the OECD, namely, Finland, Greece, Ireland, Portugal, Czech Republic, New Zealand, Hungary, Slovak Republic, Luxembourg, Slovenia, Estonia, and Iceland. The Egyptian GDP grew at higher rates in comparison to any of the countries in the OECD between 2009 and 2013.

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V. Gross Domestic Product Per Capita: Egypt
The GDP per capita for Egypt grew at a CAGR of 8.2 per cent between 2008 and 2013 to reach USD 3,243 (EGP 20,947) in 2013 from USD 2,183 (EGP 12,036) in 2008. As per IMF estimates, the GDP per capita of Egypt is expected to grow at a rate of 9.6 per cent to reach approximately USD 5,609 (EGP 44,085) by 2019.

Exhibit 1.14: GDP Per Capita, Egypt, 2008-2013, 2019
EGP 12,036 13,695 15,509 17,225 19,355 20,947 44,085 5,609 3,222 3,243

USD

2,183

2,478

2,812

2,960

2008

2009

2010

2011

2012

2013

2019f

Source: IMF, Frost & Sullivan Analysis

Egypt had a higher GDP per capita growth between 2008 and 2013 as compared to selected counties in the Levant with 1.25 per cent growth rate (excluding Palestine and Syria) and the countries in the OECD at approximately 0.02 per cent. Countries in the GCC also showed a lesser per capita GDP growth (2.7 per cent) than Egypt between 2008 and 2013.

5

CAGR shown for the average of the GDP per capita in selected countries of the region

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VI. Gross Domestic Product Per Capita Comparison
The GDP Per Capita at current prices is compared with other selected countries (Exhibit: 1.15).

Exhibit 1.15: GDP Per Capita Comparison, Selected Countries, 2013
All values in USD Billion

CAGR 2008-2013
Australia Brazil Egypt India South Africa Turkey UAE Bahrain 11,173 3,243 1,509 6,621 10,721 44,552 27,926 24,953 45,189 21,456 98,986 24,867 36,926 5,174 10,077 1,856 3,077 1,12,473 1,00,579 81,276 59,129 53,001 13,435 13,388 10,650 64,578 5.6% 5.3% 8.2% 7.5% 3.7% 0.9% 2.7% -3.3% 4.4% 1.1% 0.2% 5.9% -4.7% 4.0% 6.6% 7.9% NA NA 0.0% 1.2% 3.3% -1.2% 1.9% -0.7% -2.7% 1.4%

GCC

KSA Kuwait Oman Qatar Cyprus Israel

LEVANT

Jordan Lebanon Palestine* Syria* Luxembourg Norway Switzerland

OCED

Denmark US Poland Hungary Mexico

*Values shown for Palestine and Syria are for 2012 Source: IMF-2014, Frost & Sullivan Analysis

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According to IMF estimates, the GDP per capita of Egypt was approximately USD 3,243 in 2013. Developed countries like the United States and Australia have a high GDP per capita of approximately USD 53,000 and 64,578, respectively. Countries like the UAE and Brazil have approximately USD 44,550 and 11,170, respectively. India has a GDP per capita of USD 1,509. Countries in the GCC: Amongst the countries in the GCC, Qatar had a very high GDP per capita of approximately USD 98,986 in 2013, while Kuwait had approximately USD 45,190. As of 2013, Egypt has comparatively less GDP per capita as compared to these countries. Countries in the Levant: Amongst the countries in this region, Israel has the highest GDP per capita of approximately USD 36,926 and Jordan is on lower side with approximately USD 5,174. Amongst these countries, GDP per capita of Egypt is comparative to that of Syria, which had value of USD 3,077 in 2013. Countries in the OECD: Countries like Luxembourg, Norway, and Switzerland had the highest GDP per capita of approximately USD 112,470, 100,580, and 81,276 in 2013, respectively. Poland, Hungary, and Mexico have low GDP per capita of approximately USD 13,435, 13,390, and 10,650, respectively. The GDP per capita of Egypt is lesser than the countries in the OECD but the growth has been higher in comparison to any of these countries between 2008 and 2013.

GDP Per Capita Growth Rate Projections (2013 to 2018E): The Egyptian market is expected to show a higher growth in its GDP per capita between 2013 and 2018, when compared to other selected countries and regions.

Exhibit 1.16: GDP per Capita CAGR Comparison, 2013A-18E
7.7% 2.4% 2.9% 3.2% 3.3% 3.4% 4.1% 5.5% 9.0%

0.8%

1.4%

1.6%
South Africa

GCC (a) Australia

UAE

Levant (b)

Brazil OECD (c) Turkey

USA

North Africa (d)

India

Egypt

Note: (a) GCC includes average of Bahrain, Kuwait, Oman, Qatar, KSA and UAE (b) North Africa includes average of Algeria, Libya, Morocco, Sudan and Tunisia (c) Levant includes average of Cyprus, Israel, Jordan and Lebanon (d) OECD includes average of Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, South Korea, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, UK, US Source: IMF; Frost & Sullivan

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VII. Consumer Expenditure: Egypt
Driven by its fast growing population, consumer expenditure in Egypt has grown by approximately 2.3 per cent between 2008 and 2013. The rising consumer expenditure in Egypt could be easily accessed from the fact that the consumption by the population in 2013 made up around 93 per cent of its GDP.

Exhibit 1.17: Final Consumption Expenditure, Egypt, 2008-2013
All Values as per cent of GDP

92 87 86 87

93

83

2008

2009

2010

2011

2012

2013

Source: IMF, Frost & Sullivan Analysis

The Household Consumption Expenditure (*all goods and services, including durable products such as cars, washing machines, and home computers) holds a significant share in the consumption expenditure in Egypt over the Government Consumption Expenditure. It grew at a CAGR of 2.5 per cent between 2008 and 2013 against the Government Consumption Expenditure, which grew at a CAGR of 1.5 per cent between 2008 and 2013. As compared to the MENA, the consumption expenditure in Egypt has been considerably higher showing growth since 2010 unlike the MENA with a decline since 2010.

Recent trends of Household Expenditure in Egypt: • With the increase in the minimum wages by the Government in January 2014 to USD 168 (Egyptian Pound (EGP) 1,200) from USD 98 (EGP 700), the household consumption is likely to increase in the coming years and consequently the economic growth is likely to grow. With a constant rise in the population, the household expenditure has seen significant growth in the recent years. As in most developing countries, food dominates the consumer expenditure and is expected to grow.

• •

Inflation Rates Inflation of consumer prices in Egypt has shown improvement in between 2008 and 2012, even though the inflation rates are higher in Egypt compared to other key countries in the GCC and the Levant.

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Increase in fuel and electricity prices have raised prices of other commodities and contributed to the rise in inflation. As of 2014, the urban consumer price index has hit highest rates compared to 2008.

18.3

Exhibit 1.18: Consumer Price Index in Anuual percentage, Egypt, 2008-2013
11.8 11.3

10.1 7.1

9.5

2008

2009

2010

2011

2012

2013

Source: CAPMAS, World Bank Data on Inflation’ Egypt-2014, Frost & Sullivan Analysis

The main reason for the increasing inflation rates post 2012 is the low value of the Egyptian pound, which has severely pushed up prices of local products. The rise in the price of the dollar has led to an increase in the prices of imported products, especially since Egypt imports about 80 per cent of its needs.

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Section 2: Overview of the Egyptian Healthcare Services System

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Section 2: Overview of Egyptian Healthcare Service System
I. Healthcare System Structure
The healthcare system of Egypt is discrete with multiple stakeholders playing co-ordinated role at various levels. Broadly, the ownership by provider type can be divided into the public and the private sector. Under the public health system, the Ministry of Health and Population (MOHP) has a major role to play with its own health facilities and those owned by the Semi Government (parastatal) sector. Apart from these two, there are other ministries like Interiors, Transport and Defence which have their own health facilities. The dominant private sector of Egypt also follows the regulations laid by MOHP and has presence at all the levels of healthcare. Exhibit 2.1: Healthcare System Structure, Egypt
Egyptian Healthcare Sector

Public Scetor

Quasi-Government / Parastatal Sector

Private Sector

MOHP

Ministry of Higher Education (MOHE)

Other Ministries

Health Insurance Organisation (HIO)

Private Hospitals / Clinics / Doctors

Levels of Care

Ministry of Interiors

Hospital s

Teaching hospital and institutes organisation

Non-governmental Organisation

Centres without Beds Basic Health Units

The Transport Ministry Curative Care Organisation The Defence Hospital

Private Voluntary Organisation

Source: Healthcare System Egypt USAID-2020, NHA Egypt-2008-09, CAPMAS, Frost & Sullivan Analysis

Public Healthcare System Structure: The public healthcare structure, as explained in the above exhibit, has various components to it, which are: • MOHP: The MOHP is the supreme provider of healthcare services in Egypt, providing healthcare at all levels including primary, preventive, and curative. It provides services via a network of

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general hospitals, district hospitals, specialty hospitals, and primary healthcare centres (PHC). It also acts as the policy making body and lays down the regulatory framework of healthcare services in Egypt. • MOHE: The MOHE looks after promotion of higher medical education in Egypt with its own university hospitals, which provide primary, secondary, and tertiary levels of care services. Other Ministries: Besides the MOHP, there are healthcare facilities provided by other ministries such as Interiors, Transportation, and Defence, which are targeted towards providing healthcare to their employees and dependents. o o o • The Ministry of Interiors, with nearly 1,368 beds, is one of the most important operating health facilities for Police and Prison population. The Transport Ministry operates two hospitals with 400 beds for railway employees. The Ministry of Defence operates health facilities for the armed forces.



The Parastatal Sector: It comprises the quasi-governmental organisation supported directly by the government through the MOHP. The sector has various independent bodies with health facilities aiming at different levels of healthcare needs of patients and they also have different sources of financing. They also have varied business intentions. These organisations are: o Autonomous Bodies acting under the MOHP: Health facilities under these bodies provide services to patients of HIO, MOHP, private firms, public firms as well as the private households. Teaching Hospitals and Institute Organisation: It provides services at primary, secondary and tertiary levels of healthcare through General hospitals and research institutes. Majority of the services offered by them are free of cost. The THIO depends for its finance on Ministry of Finance, MOHP, private firms, international donors, and out-of-pocket spend by households. Curative Care Organisation: It provides free emergency services under the contract with the Government of Egypt (GoE). It runs independently on nonprofit basis and reinvests the surplus revenue for service improvement. It receives funding from HIO and MOHP contracts, private companies, and out-ofpocket spend by individuals. o HIO: Established in 1964, it is an independent governmental organisation running under the MOHP. This organisation is the primary provider of health insurance in Egypt. The HIO raises funds via premiums and co-payments from households. The HIO was created as the umbrella organisation that would provide all Egyptians with insurance and care.

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Today, it covers only government employees and schoolchildren. As per the latest available data of 2010, the HIO had its own network of 37 hospitals, 600 clinics, 78 work-related injury centres, 34 general practitioners committee, and thousands of school clinics. The insurance network outsources / had empanelment with 640 hospitals and 1,141 outpatient clinics. Private Healthcare System Structure: The private sector healthcare delivery system comprises clinics, medical centres, pharmacies, and hospitals. The private sector is well established for long in Egypt, with more facilities concentrated in major governorates and cities. It has presence at all levels of care of the healthcare sector of Egypt. The private sector of Egypt faces a challenge in terms of a large unorganised market. There are a few other organisations, which are also included under the private sector; they are the Nongovernmental Organisation (NGO) and Private Voluntary Organisation. Private Voluntary Organisations are the religiously affiliated clinics and charitable organisations of private ownership. For ease of clarity, the following sections will enunciate the infrastructure in two broad categories of public and private healthcare at tertiary, secondary, and primary level of care.

II. Healthcare Infrastructure by Level of Care
Quaternary / Tertiary Care: The top most level of the healthcare value chain in Egypt is composed of quaternary and tertiary care services provided by hospitals and university hospitals, which are owned and operated by the public as well as the private sector. As of 2012, Egypt had 1,997 hospitals in the public and the private sector together; the number of hospitals grew at a CAGR of 0.7 per cent between 2008 and 2012. Exhibit 2.2: Number of Hospitals by Public and Private Sector, Egypt, 2008-2012
CAGR: 0.7% N= 1,942 67% 1,899 65% 1,912 65% 1,908 66% 1,997 68%

33% 2008

35% 2009 % of Private Sector Hospitals

35% 2010

34% 2011 % of Public Sector Hospitals

32% 2012

Source: CAPMAS-2014, Frost & Sullivan Analysis

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The number of hospitals in the private sector has increased from 1,305 in 2008 to 1,351 in 2012, marking a 0.9 per cent growth. However, despite the number of hospitals being low in the public sector, it had a major share in hospital beds at 75 per cent of the total hospital beds available in Egypt as of 2012. This is attributed to the large size district hospitals and university hospitals run by the Government. Exhibit 2.3: Number of Hospital Beds by Public and Private Sector, Egypt, 2008-2012
136,882 20% 129,472 21% 127,733 23% 127,712 23% 128,473 25%

80%

79%

77%

77%

75%

2008

2009 % of Public Hospital Beds

2010

2011 % of Private Hospital Beds

2012

Source: CAPMAS-2014, Frost & Sullivan Analysis

The total number of hospital beds in the private sector grew from 26,814 in 2008 to 31,653 in 2012, marking a 4.2 per cent growth. The increased share of private hospital beds out of total available in Egypt, is also because of the decrease in public hospital beds between 2008 and 2012 (see exhibit 2.3). Cairo (24 per cent) and Giza (11 per cent) comprise 35 per cent of the total number of hospitals in Egypt as of 2012. Other governorates with high concentration of the hospitals are Dakahlia (9 per cent) and Alexandria (7 per cent). Private sector hospitals are also more in these four governorates (see exhibit 2.4). Cairo, Alexandria, Giza, and Dakahlia contribute to 48 per cent of the total hospital beds available in Egypt. The average beds per hospital in Cairo, Giza, and Alexandria stood at 67, 40, and 85, respectively, which signify that there are many small to medium level of facilities in Cairo and Giza (see exhibit 2.5).

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Exhibit 2.4: Top Governorates by Number of Hospitals, Egypt, 2012 N=1,997 Cairo Giza Dakahlia Alexandria Gharbia Kalyoubia Sharkia Menoufia Asyout Ismailia Others
% of Total

Exhibit 2.5: Top Governorates by Number of Hospital Beds, Egypt, 2012 N=128,473 Cairo Alexandria Giza Dakahlia Kalyoubia Gharbia Sharkia Asyout Meoufia Suhag Others
12,514 9,115 8,232 7,396 6,750 6,517 6,352 5,043 4,269 29,956
% of Total

480 226 176 148 101 91 86 77 68 52 492

24 11 9 7 5 5 4 4 3 3 25

32,329

25 10 7 6 6 5 5 5 4 3 23

Source: CAPMAS-2014, Frost & Sullivan Analysis

Quaternary / Tertiary Care in the Public Sector The public hospitals are owned directly by the MOHP, other ministries, and organisations, which are a part of the parastatal sector such as the HIO, THO, and CCO. The MOHP operates its own hospitals and acts as a controlling or supervisory body to the other institutions operating their hospitals. Although, the number of public hospital beds has seen a decrease over the years, the bed distribution in the public sector by type of institutions owned and supervised by the MOHP are explained in exhibit 2.6.

Exhibit 2.6: Distribution of Public Hospital Beds, Egypt, 2008-2012
110,068 27% 25% 48% 102,753 30% 25% 45% 2009 MOH Hospitals 98,865 31% 24% 45% 2010 Supervised by MOH 98,319 31% 25% 44% 2011 96,820 32% 25% 43% 2012

2008

Other Government Authorities
Source: CAPMAS-2014

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The health facilities supervised by the MOH are Specialised Medical Centres, Psychiatric Hospitals, Educational Hospitals and Institutes, Government Health Insurance Hospitals, and the Medical Authority. The other Government authorities’ health facilities include University hospitals, Police and Prison Hospitals, Railway Hospitals, and other facilities by other ministries. Cairo has 96 hospitals, making it the most concentrated city by number of public hospitals, followed by Dakahlia, Alexandria, and Sharkia at 42, 39, and 38 hospitals, respectively, out of 646 public hospitals in Egypt, as of 2012. University hospital beds and beds in the MOHP hospitals form a major share at 71 per cent of total public hospital beds in Egypt. According to concentration of public beds, Cairo, Alexandria, Dakahlia, and Kalyoubia are the top four governorates. The Cairo governorate houses approximately 22,617 beds, which is 23 per cent of the total 96,820 public beds available in Egypt, as of 2012. Quaternary / Tertiary Care in the Private Sector The private sector in Egypt has a network of general to specialised hospitals from small and medium to large-scale capacity in nature. The private sector holds a major share in the healthcare system with ~1,351 hospitals (~68 per cent of the total number of hospitals) in 2012. The concentration of private hospitals is comparatively higher in the governorates like Cairo, Giza, Dakahlia, and Alexandria. Together, these four governorates contain ~60 per cent of the total private hospitals in Egypt (see exhibit 2.7).

Exhibit 2.7: Top Governorates by Number of Private Hospitals, Egypt, 2012 % of Total N=1,351 Cairo Giza Dakahlia Alexandria Gharbia Kalyoubia Sharkia Menoufia Asyout Ismailia Others
384 192 134 109 68 58 48 48 45 36 229
28 14 10 8 5 4 4 4 3 3 17

Exhibit 2.8: Top Governorates by Number of Private Hospital Beds, Egypt, 2012 % of Total N=31,653 Cairo Giza Alexandria Gharbia Dakahlia Sharkia Asyout Kalyoubia Menoufia Ismailia Others
4,148 2,937 2,056 1,944 1,858 1,116 1,110 1,068 336 5,368 9,712
31 13 9 6 6 6 4 4 3 1 17

Source: CAPMAS-2014, Frost & Sullivan Analysis

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Cairo has the maximum concentration of private hospital beds. As of 2012, the top four governorates of Cairo, Giza, Alexandria, and Gharbia accounted to 60 per cent of the total private hospital beds available in Egypt (see exhibit 2.8). The average number of beds per hospital in the private sector is between 20 and 40 in key governorates. Cairo, Giza, Alexandria, and Dakahlia has 25, 22, 27, and 15 beds per hospital, respectively, which further signifies that the majority of health facilities in the private sector are small to medium scale in nature. In the private sector, some of the well-known hospitals are Al Salam International Hospital, Magrabi Hospital, Dar Al Fouad Hospital, International Medical Centre, Nile Badrawi Hospital, Dar El Oyoun Eye Institution, Miami Private Hospital, and Victoria Hospital.

Secondary / Primary Care: Secondary and Primary Level of Care in the Public Sector: The MOHP is the key provider of Secondary and Primary healthcare services in Egypt. It provides services via a network of specialised clinics dealing with various diseases. There are primary health centres (PHC) / clinics run by other bodies like parastatal organisation (THO, HIO and CCO). The secondary level of care by the public sector can be broadly categorised into independent specialty clinics, urban dental units, rural dental units, and others, comprising pre-marriage check-up clinics and medical committees (see exhibit 2.9).

Exhibit 2.9: Public Health Units Without Beds by Specialisation, Egypt, 2008-2012
3,139 2% 70% 3,340 2% 3,737 8% 3,862 9% 4,302 10%

73%

70%

69%

72%

27% 1% 2008

24% 1% 2009

21% 1% 2010 Urban Dental Units

21% 1% 2011 Rural Dental Units

18% 1% 2012 Others

Independent Specialty Clinics

Source: CAPMAS-2014

In 2012, there were about 4,300 health services units operated by the public sector. There has been more focus on the dental services by the public sector always in both rural and urban areas, with about 90 per cent of the clinics offering dental services, as of 2012 (see exhibit 2.9).

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At the primary level of care, there are about 5,200 Basic Health Unit operated by the Government and other Government bodies. The GoE has a strong focus on delivering health services to the rural areas with maximum addition of basic healthcare units over the past few years (see exhibit 2.10). During 20082012, there has been an addition of ~260 new basic healthcare units in these areas. On the contrary, the urban healthcare centres have seen a decline in numbers by ~250 over 2008-2012.

Exhibit 2.10: Number of Basic Healthcare Units, Egypt, 2008-2012 Year Sector 2008 2009 2010 2011 Health Offices (Small Clinics) 324 322 315 314 District Clinics (Comprehensive) 105 109 77 74 Motherhood and Childhood Care Centres 175 178 162 156 Urban Health Centers 342 343 208 154 Health Care Units (Medicine) 229 294 Basic Care Units in Rural Areas Total 3,983 4,929 3,996 4,948 4,112 5,103 4,144 5,136

2012 329 90 149 91 359 4,245 5,263

Source: CAPMAS-2014

Secondary and Primary Level of Care in the Private Sector: To fulfil primary healthcare needs, the people of Egypt heavily rely upon private doctors and clinics. Amongst all the healthcare facilities across the public and private healthcare sectors, private doctors (also denoted as ‘Office of Physicians’) cater to the maximum number of patients. Besides the private doctors, there are clinics run by NGOs) preferred for primary care in private sector. The private sector has medical centres, clinics, laboratories, blood banks, diagnostic centres, and day surgery centres, apart from a network of hospitals. There is a huge unaccounted base of unorganised private sector market at all levels of care and facility type in Egypt.

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III. Healthcare Expenditure: Egypt
The expenditure on healthcare in Egypt stood at USD 12.7 billion, at a CAGR of 14.3 per cent between 2007 and 2012. The healthcare expenditure stood at 5.0 per cent of the GDP as of 2012, which was 4.9 per cent in year 2007.
All Values in USD billion

Exhibit 2.11: Total Healthcare Expenditure, Egypt, 2007-2012
CAGR: 14.3%

6.5
59%

7.9
58%

9.4
59%

10.2
61%

11.3
59%

12.7
61%

41% 2007

42% 2008

41% 2009

39% 2010

41% 2011

39% 2012

Private Expenditure as % of Total Healthcare Expenditure

Public Expenditure as % of Total Healthcare Expenditure

Source: WHO, Frost & Sullivan Analysis

Public expenditure on healthcare is low compared to private expenditure; it stood at USD 5 billion and USD 7.8 billion as of 2012, respectively. Over the years, the share of contribution by the Government on healthcare expenditure has been decreasing with increase in private expenditure. Exhibit 2.12: General Government Expenditure on Healthcare, Egypt, 2007-2012 All Values in
USD billion

Exhibit 2.13: Private Expenditure on Healthcare, Egypt, 2007-2012
All Values in USD billion

CAGR: 15.2%

CAGR: 12.9%

2.7

3.3

3.9

4.0

4.6

5.0 3.8 4.6

5.5

6.2

6.7

7.8

2007

2008

2009

2010

2011

2012

2007

2008

2009

2010

2011

2012

Source: WHO, Frost & Sullivan Analysis

The public and private expenditure on healthcare grew at a CAGR of 12.9 per cent and 15.2 per cent between 2007 and 2012, respectively. There has been no substantial increase in Government budgets for healthcare; therefore, contribution by the Government is slowly decreasing in the overall healthcare expenditure scenario.

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Egypt has pluralistic and complex financing mechanisms, which are tax-based financing, health insurance, and fee for service through OOP expenditures. As of 2012, private expenditure on healthcare is largely contributed by OOP expenses, while contribution by private insurance and private non-profit institutions is very low at 2-3 per cent.

Exhibit 2.14: Private Sector Expenditure Contribution by Sources, Egypt, 2012
External Funds, 0.7% Private Insurance, 1.7%

Exhibit 2.15: Out-of-Pocket Expenditure on Healthcare, Egypt, 2007-2012
All Values in USD billion

Out-ofpocket, 97.7%

CAGR: 15.1% 7.6 5.4 6.0 6.6 4.5

3.8

NGOs, 0.2% 2007 2008 2009 2010 2011 2012

Source: WHO, Frost & Sullivan Analysis

Out-of-pocket expenditure, being the major driver of healthcare expenditure, grew at 15.1 per cent between 2007 and 2012 contributing to almost 97.4 per cent of the total private expenditure in Egypt. The contribution of out-of-pocket expenditure to the total healthcare expenditure has grown from 58 per cent to 60 per cent between 2007 and 2012. The percentage of out-of-pocket expenditure spending for healthcare in Egypt is very high while Government expenditure is steadily decreasing, along with minimal private insurance presence in the country, burdening private households by these costs. This private money spent on healthcare, however, does not grant unlimited access to high quality services. Most of the funding in the Egyptian healthcare system comes from and is spent in private sector based systems — a trend that is likely to increase in future. The Government has some discrete plans on universal coverage to control the increasing burden of cost.

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IV. Healthcare Expenditure Comparison
Exhibit 2.16: Healthcare Expenditure, Selected Countries, 2012
All Values in USD Billion

CAGR 2007-2012 Australia Brazil Egypt India South Africa Turkey UAE Bahrain 140.7 209.9 12.7 75.9 33.8 49.7 10.9 1.2 22.8 4.6 2.0 4.2 1.7 18.1 2.7 3.0 0.9 2.2 2,809.0 600.8 383.3 306.4 229.8 3.9 1.3 1.2 -0.9% 2.3% 3.6% -8.2% 10.8% 12.6% 14.3% 10.1% 8.7% 5.0% 11.2% 12.1% 9.6% 13.8% 14.2% 17.7% 5.2% 7.7% 13.7% 8.7% 16.5% 7.6% 4.5% 10.9% 1.9% 1.8%

% of GDP 9.1 9.3 5.0 4.0 8.8 6.3 2.8 3.9 3.2 2.5 2.6 2.2 7.3 7.5 9.8 7.3 7.9 3.4 17.9 10.1 11.3 11.7 9.4 6.9 5.9 9.1

GCC

KSA Kuwait Oman Qatar Cyprus

LEVANT

Israel Jordan Lebanon Palestine Syria US Japan Germany

OECD

France United Kingdom Luxembourg Estonia Iceland

Source: WHO National Health Accounts-2014, Frost & Sullivan Analysis

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Egypt had a higher growth in total healthcare expenditure at 14.3 per cent between 2007 and 2012 as compared to countries in the Levant with combined growth rate of 8.4 per cent and OECD countries, which has a low growth of approximately 4.3 per cent. According to WHO national health accounts, the healthcare expenditure of Egypt stood at USD 12.7 billion in 2012, and is much lower when compared to those of developed countries like the United States, Brazil, and Australia, which stood at USD 2,800, 210, and 141 billion, respectively. Countries in the GCC: The healthcare expenditure of Egypt is higher than most of the countries in GCC like UAE, Bahrain, Kuwait, Oman, and Qatar, which have expenditure in the order of USD 10.9, 1.2, 4.6, 2, and 4.2 billion, respectively. As of 2012, healthcare expenditure in KSA was almost double as compared to Egypt at USD 23 billion. Countries in the Levant: Amongst all the countries in the Levant, Israel had the highest healthcare expenditure at USD 18 billion in 2012, followed by other countries which had a low spending on healthcare (between USD 1 to 3 billion). Countries in the OECD: The top countries in terms of healthcare expenditure in the OECD are the US, Japan, Germany, France, and the United Kingdom at USD 2,809, 600, 383, 306, and 230 billion, respectively. Luxembourg, Estonia, and Iceland had the lowest expenditure amongst the countries in OECD with USD 4, 1.3, and 1.2 billion, respectively. As of 2012, the total expenditure on healthcare of Egypt was better than six countries in the OECD —Hungary, Slovak Republic, Slovenia, Luxembourg, Estonia, and Iceland.

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V. Per Capita Healthcare Expenditure: Egypt
The per capita expenditure on health in Egypt grew 1.5 times between 2007 and 2012. The per capita expenditure on health stood at USD 152 (EGP 918) in 2012, marking a CAGR of 12.3 per cent between 2007 and 2012.

Exhibit 2.17: Per Capita Expenditure on Healthcare, Egypt, 2007-2012
CAGR: 12.3% EGP USD 479 85 550 101 652 118 707 126 814 137 918 152

2007

2008

2009

2010

2011

2012

Source: WHO, Frost & Sullivan Analysis

Egypt has a lower per capita expenditure on health as compared to countries of the GCC, the Levant, and the OECD. This is mainly attributed to the country’s huge population and high fertility rates. The growth in per capita healthcare expenditure of Egypt (12.3 per cent) is higher as compared to the countries in the GCC, the Levant, and the OECD at 6.1 per cent, 5.2 per cent, and 2.3 per cent, respectively between 2007 and 2012.

VI. Per Capita Healthcare Expenditure Comparison
According to the WHO National Health accounts, per capita healthcare expenditure of Egypt was approximately USD 152 in 2012 (see exhibit: 2.18). Some countries like the United States and Australia had high per capita expenditure in order of USD 8,895 and 6,140, respectively. Egypt has higher per capita healthcare expenditure than India, which is USD 61. Amongst the countries in the GCC, Qatar has a very high per capita healthcare expenditure of approximately USD 2,000, while Kuwait’s approximately USD 1,400 is high too. Amongst the countries in the Levant, Israel has the highest per capita spending on healthcare at USD 2,289, while Palestine and Syria had the lower spending per capita at USD 234 and USD 105, respectively. Amongst the countries in the OECD, Norway, Switzerland, the US, Luxembourg, and Denmark had a high per capita expenditure on health and countries like Hungary, Poland, and Mexico stood at lowest per capita spend, as of 2012.

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Exhibit 2.18: Per Capita Healthcare Expenditure, Selected Countries, 2012
All Values in USD

Australia Brazil Egypt India South Africa Turkey UAE Bahrain KSA Kuwait Oman Qatar Cyprus Israel Jordan Lebanon Palestine Syria Norway Switzerland US 388 650 234 105 152 61 645 665 1,343 886 795 1,400 688 2,026 1,949 2,289 1,056

6,140

CAGR 2007-2012 9.2% 11.6% 12.3% 8.7% 7.5% 3.6% 2.6% 6.8% 7.0% 8.5% 11.4% 4.9% 2.9% 5.8% 9.0% 6.3% 13.2% 5.7% 9,055 8,980 8,895 7,452 2.6% 7.95% 3.5% 0.3% 2.0% -1.6% -1.0% 3.9% 1.8%

OECD

LEVANT

GCC

Luxembourg Denmark United Kingdom Hungary Poland Mexico 987 854 618 3,647

6,304

Source: WHO National Health Accounts-2014, Frost & Sullivan Analysis

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Per Capita Healthcare Expenditure Projection – Egypt (2014E-2018E): The healthcare expenditure per capita of Egypt is expected to reach USD 305 by 2018 as compared to USD 191 in 2014, with a CAGR of 12.4 per cent between 2014 and 2018. Private expenditure is expected to grow at a CAGR of 13.2 per cent as compared 11.0 per cent in public expenditure between 2014 and 2018. Exhibit 2.19: Per Capita Healthcare Expenditure, Egypt, 2014 - 2018 305
36%

(USD)

191
38% 62% 2014E

215
38% 62% 2015E Private Spending

241
37% 63% 2016E

271
37% 63% 2017E

64%

2018E

Public Spending
Source: CAPMAS Egypt, WHO, Frost & Sullivan Analysis

Per Capita Healthcare Expenditure Projection – Jordan (2014E-2018E): The healthcare expenditure per capita of Jordan is expected to reach USD 653 by 2018 as compared to USD 461 in 2014, with a CAGR of 9.1 per cent between 2014 and 2018. Private expenditure is expected to grow at a CAGR of 7.1 per cent as compared 10.1 per cent in public expenditure between 2014 and 2018. Exhibit 2.20: Per Capita Healthcare Expenditure, Jordan, 2014 - 2018 549
66% 34% 2016E

599
66%

653

461 (USD)
64% 36% 2014E

503
65% 35% 2015E Private Spending

67%

34% 2017E

33% 2018E

Public Spending
Source: WHO, Frost & Sullivan Analysis

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Per Capita Healthcare Expenditure Projections – Sudan (2014E-2018E): The healthcare expenditure per capita of Sudan is expected to reach USD 174 by 2018 as compared to USD 131 in 2014, with a CAGR of 7.3 per cent between 2014 and 2018. Private expenditure is expected to grow at a CAGR of 7.4 per cent as compared -0.9 per cent in public expenditure between 2014 and 2018. Exhibit 2.21: Per Capita Healthcare Expenditure, Sudan, 2014 - 2018 162
16% 84%

131 (USD)
20% 80% 2014E

140
19% 81%

151
17% 83%

174
15%

85%

2015E Private Spending

2016E

2017E

2018E

Public Spending
Source: WHO, Frost & Sullivan Analysis

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VII. Health Insurance System
Overall Insurance Scenario: The insurance premiums collected in Egypt in 2012 were USD 1.8 billion and it saw a growth of 6.1 per cent over the previous year. Exhibit 2.22: Insurance Scenario, Egypt, 2012 Insurance Regulator Egyptian Financial Supervisory Authority (EFSA) Insurance Association Insurance Federation of Egypt (IFE) Total Number of Insurers / Reinsurers 29 (19 in Non-life segment) Life Premiums Collected USD 785 million Non-Life Premiums Collected USD 1,033 million Insurance Density USD 21.7 Insurance Penetration 0.73% Top Five Companies by Net Premiums in USD Million, 2012 Misr Insurance 0.27 Misr Life 0.22 Allianz Life 0.12 MetLife Alico 0.11 Commercial International Life 0.07
Source: MENA Insurance Review Report-AIG-2013, Swiss Re sigma No 3/20

The insurance sector has suffered huge losses since the outbreak of the 2011 revolution (Arab Spring), most of which are from property damages due to increased rates of violence and rioting.

Insurance Sector Comparison with Selected Countries: The non-life segment majorly contributed (85 per cent) to the USD 44.1-billion insurance market of the MENA in 2012. The penetration of insurance in the MENA as a share of GDP was 1.5 per cent in 2012 and the premium per capita stood at USD 306. The five countries with higher premium collections than that of Egypt are Turkey, Iran, KSA, UAE, and Morocco. At 1.0 billion premiums of non-life segment in Egypt in 2012, the country lags behind other countries in the MENA such as Turkey, Iran, KSA, UAE, Morocco, Qatar, and Algeria (see exhibit 2.23). The insurance market of Egypt was pegged at USD 1.8 billion in 2012, which marked a growth of 6.1 per cent over the previous year. The non-life segment contributes more to the total sector at 57 per cent; both the life and non-life segments grew at same rate of 6.1 between 2011 and 2012. Health insurance contributes approximately 11-12 per cent of the non-life segment. The penetration of insurance as a share of GDP was 0.73 per cent in 2012 and the premium per capita was USD 21.7.

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Exhibit 2.23: Insurance Sector Comparison with Selected Countries, 2012 Premiums Non-Life Insurance Insurance Density Region / Countries Total % growth Contributi Growth Penetration (Premiums (Premiums Premiums over on to total in % as % of GDP per capita in (USD Previous Premiums USD) Million) Year Collected Turkey Iran UAE KSA Qatar Lebanon Kuwait Oman Jordan Bahrain Morocco Egypt Algeria Tunisia MENA Asia (including Japan) Africa Europe 10,882 8,222 7,190 5,455 1,300 1,295 970 762 659 627 2,857 1,818 1,250 816 44,103 1,346,223 71,891 1,535,176 8.0 0.7 10.4 10.5 8.6 4.0 18.5 4.1 7.2 9.6 (2.5) 6.1 5.2 (2.4) 6.2 5.3 3.8 (5.6) 84% 92% 80% 96% 96% 71% 81% 84% 91% 77% 67% 57% 93% 85% 84% 29% 31% 43% 7.9 0.7 9.8 11.2 8.6 3.7 18.5 4.1 7.2 9.6 (2.5) 6.1 6.0 (2.4) 6.2 7.8 (1.2) (4.1)

1.4 1.7 2.0 0.8 0.6 2.9 0.5 1.0 2.1 2.0 3.0 0.7 0.7 1.8 1.5 5.7 3.7 6.7

145.9 108.8 1,464.2 190.2 695.9 301.9 337.1 263.6 102.5 449.6 87.6 21.7 34.3 76.3 305.7 321.7 67.3 1,724.4

Source: MENA Insurance Review Report-AIG-2013, Swiss Re sigma No 3/20

Health Insurance Introduction: The healthcare system in Egypt is dynamic and involves great complexity, which incorporates both the public and private sectors of the health insurance market. There are few providers of health insurance in Egypt and penetration rates remain lower in comparison with Brazil, Turkey, Tunisia, Iran, and Jordan, countries with penetration above 85 per cent of its total population. Insurance from the Health Insurance Organisation (HIO) covers 54.4 per cent of the total population. Apart from the basic Government health insurance by the HIO, another 1.3 per cent is enrolled in private health insurance schemes and the remaining 44.3 per cent of Egyptians have no health insurance at all.

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Health Insurance Structure: Public Health Insurance: The main insurance provider in Egypt is the HIO. It was established in 1964 with the intention of providing social health insurance to formal workers and extending coverage to the whole population. Besides its function as a social health insurance body, the HIO is an important provider of health services through its own network of facilities. • Beneficiaries: The beneficiaries of the HIO are Government employees, public and private sector employees, students, widows, pensioners, and new-borns. Most of the people not covered by the HIO belong to low-income groups. Coverage rates across regions vary considerably because of different population structures in the regions. In 2010, about 35 million Egyptians were covered by public medical insurance, which grew to 45 million by 2012. The introduction of new regulations like the insurance schemes for students and pre-school children caused a considerable extension of the HIO coverage. Therefore, most of the insured under HIO are children followed by Government employees. Widows are covered under a separate programme, but do not make premium payments. Small co-payments are required from some workers, but these are quite small when compared to the benefits provided. • Network: Apart from its own health facilities network, the HIO also had tie-ups with 640 hospitals and 1,141 clinics in Egypt in 2012. Funding: Although the HIO operates as an insurance agency, in practice, its annual expenditures are greater than its income from premiums. Consequently, it receives ad hoc subsidies from the GoE so that it pays unpaid creditors, and occasionally for capital expenditures. Thus, the HIO can be regarded as a funding mechanism combining features of both social insurance as well as general revenue financing. HIO Financing Structure: The Medical Insurance budget was USD 120 million per annum in 2010, covering 530 types of medications supplied almost free of charge. o The insurance is financed by 1 per cent of citizen’s salary along with 3 per cent from the employer (4 per cent of basic salary) o o o • Employers contribute around 40 per cent of the overall revenues of the HIO The insured and the MOF each contribute a share of around 20 per cent to the HIO revenue Public firms (15 per cent) and NGOs (…...

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... The Doctor “Magistrate Communication Style” “Transformation” XXX TMGMT 314: Interpersonal Skills in the Workplace G. Kent Nelson, Ph.D. University of Washington – Tacoma 03 June, 2009 The Doctor Introduction The Doctor is a film that outlines the ways that doctors around the world think. It is about a doctor who finds out the hard way that there's more to medicine than skill in the operating theater in this emotional drama. The main character is Jack McKee, who is a gifted but arrogant surgeon. He cares little about the emotional welfare of his patients and is little more than a benign stranger to his wife Anne and his son Nicky. He has been suffering from a nagging cough for some time, and when he begins coughing up blood one morning, he finally allows another doctor to take a look at him. The doctor discovers that he has a malignant tumor in his throat that could rob him of the ability to speak, or even kill him. He now becomes a patient instead of a doctor, and learns first hand about the long stretches in the waiting room, the indignity of filling out pointless forms, and the callous attitude of the professional medical community. He also gets to know June, a terminal cancer patient whose joyous embrace of life as her time draws to a close is an inspiration to him. After recovery, Jack becomes more determined to be a caring healer and strives to be a better husband and father. But his new outlook on life turns former friends into foes, and dislike co-workers in...

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...approached about not being able to talk to Anne, he really started to need Anne in which he relays to her shortly after his surgery. It is ok Jack, I have always wanted to slit your throat…now I have the chance to do just that. To Jack, it is very much a boys game sort of like a clique and if colleagues do not play the game his way, colleagues do not get respect. Jack has his “guys”, the ones whose back he covers and vice versa then he has his colleagues that he completely disrespects for the compassionate way they practice. It was not until he, as a patient, was treated how he initially treated his patients that he realized, compassion is such a big part of what he does on a daily basis. In the end, it is profound how he realizes that every doctor becomes a patient somewhere down the line. When he realizes that, it is no longer a boys’ game and he starts standing up for what is right, especially when he finds out his colleague, before performing surgery on a man who is now suing them, tore up a patients’ records. As for the colleague who he continually disrespected, he later became the surgeon that Dr. MacKee needed the most. When you have thirty seconds before a guy bleeds out, I would rather you cut straight and care less. Dr. MacKee is so callous towards his patients in the beginning. The initial scene, the audience witnesses where Dr. MacKee is saving a man who attempted suicide, after the surgery is completed, his associates ask if there is anything that he......

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...Ijoma, Ikenna Onwuekwe, Obinna Onodugo, Emmanuel Aguwa, Emmanuel Ejim, Cajetan Onyedum, Linus Onah, Emecheta Okwudire, Geraldine Ugwuonah. Effect of Promotional Strategies of Pharmaceutical Companies on Doctors' Prescription Pattern in South East Nigeria. TAF Prev Med Bull. 2010; 9(1): 1-6. Lurie N, Rich EC, Simpson DE. et al. Pharmaceutical representatives in academic medical centers. J Gen Intern Med.1990;5:240-243. Abdus Salam, Mainul Haque, Zakirul Islam, Asadul Mazid Helali, et al. Comparative study of professionalism of future medical professionals among three private medical colleges of Bangladesh. Asian J Pharm Clin Res, 2013; 6(3): 170-9. Orlowski, James P., and Wateska, Leon (1992). The effects of pharmaceutical firm enticements on physician prescribing patterns: there’s no such thing as a free lunch. Chest.102, 270-274. Brett AS, Burr W, Moloo J. Are gifts from pharmaceutical companies ethically problematic? A survey of physicians. Arch Intern Med. 2003 Oct 13;163(18):2213-8. Steven P Higgins MD. Drug representatives: Giving you lunch or stealing your soul?. Dermatology Online Journal 2007; 13 (4): 5. Gagnon MA, Lexchin J: The cost of pushing pills: a new estimate of pharmaceutical promotion expenditures in the United States. PLoS Med 2008, 5(1):e1. Campbell EG: Doctors and drug companies—scrutinizing influential relationships. N Engl J Med 2007, 357(18):1796– 1797. Haayer F. Rational prescribing and sources of information. Soc Sci Med.1982;......

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