Arab Republic of Egypt Social Sector Notes June 2016 ACKNOWLEDGMENTS In response to a request from the Government of Egypt, the World Bank undertook the analysis of selected sectoral issues in education and health and their link to public spending. The objective of the analytical task was to inform policies to enhance human development impact of social sector expenditures in line with Egypt’s new constitutional mandate, which requires earmarked increases in the government’s expenditures on health, education and research1. The studies focus primarily on the education and health sectors and constraints to achieving better outcomes in these sectors. It draws on information from the national budget, household survey data and evidence from previous analytical work. This series of studies were conducted under the overall coordination of Gustavo Demarco. The technical team included Quentin Wodon, main author of the notes, with contributions from the following co-authors: Lire Ersado, Brooks Evans, Chata Male, Adenike Onagoruwa, Aboudrahyme Savadogo, Ali Yedan, Alaa Hamed, Aaka Pande, Emelyne Calimoutou, Amr El Shalakani and Minh Cong Nguyen. Amira Kazem and Shahram Paksima provided substantive inputs to the Education note. Souraya El Assiouty provided research support and Mariam Ghaly provided general assistance to the team. This technical assistance is part of overall support to the government of Egypt, under the leadership and supervision of Asad Alam, Country Director. Poonam Gupta, Husam Abudagga, Safaa El Kogali, Hana Brixi, Yasser El Gammal, Ernest Massiah and Margaret Grosh provided guidance and substantive comments during the process and final review. Peer reviewers were Nistha Sinha, Caroline Krafft and Pablo Facundo Cuevas. The main notes produced under this task aim to provide insights into the education and health sectors in Egypt, as well as the cross-cutting issue of child marriage. While the main focus is on the education and health sectors, attention is also given to labor, since the outcomes in the labor market are directly and indirectly affected by investments in education and health. Other topics are also considered within the notes, including early childhood development and child marriage. The scope of the work is comprehensive, but limited by time and data availability, and therefore not exhaustive. A number of additional interventions of high social and developmental potential impact can be analyzed as part of future studies on the matter. 1 According to the Constitutional amendment, Egypt is required to increase spending on pre-university and university education to reach 4% and 2% of GNP, respectively, from the current total for both of around 3.5%; spending on health to 3% of GNP from less than 1.5%; and on scientific research to 1% of GNP from near zero, http://www.dailynewsegypt.com/2014/01/07/new-constitution-raises-spending-on- health-education-and-science-moussa/ Social Sector Note SELECTED CHALLENGES AND Development; (5) increased utilization OPTIONS IN THE EDUCATION of autonomy and accountability SECTOR towards more effective schools; and finally (6) innovative curriculum, This first note has two objectives. The better learning environment, more first objective is to provide a rapid effective use of ICT, and improved diagnostic of key features of the pre- teaching and learning materials. tertiary education sector in the areas of schooling (enrollment, out-of- While enrollment rates at the primary school children, reasons for ropping and secondary levels in Egypt are at out), learning (student performance or above expectations given the factors affecting performance), country’s level of economic education and labor market earnings, development, enrollment at the and finally education spending, pre-K level remains low. In addition, both by the government and by Egypt still faces challenges as many households. The second objective is children are out of school or at risk to provide a more detailed analysis of dropping, and many others do not of specific challenges identified in six continue beyond the preparatory priority areas for the government’s level. The main reason cited for education strategy: (1) school- dropping out is that children are not readiness through expanded and interested in pursuing their education, targeted provision of early childhood which may denote poor quality in education programs; (2) evidence- the education provided. But in based pedagogical approaches addition, for children and youth from and teacher professionalism; (3) disadvantaged backgrounds, public comprehensive student assessment; cash transfers could help in ensuring (4) more effective TVET and Skills that children remain in school. 5 Social Sector Note Poor learning outcomes are a serious Egypt still tends to invest less in issue, and the fact that the returns to education through the budget than education, while positive, are small other countries with similar levels of also suggests limited quality and development. The fact that enrollment learning in the education system. rates are relatively high while public For both science and mathematics, funding for education is not similarly Egypt has one of the lowest scores high may contribute to weaknesses among countries participating in in quality and lead to pressures for TIMSS. Methods of teaching in Egypt parents to pay for after class tutoring have largely focused on rote learning and other programs to help their and memorization of information children to pass examinations that instead of promoting critical thinking, matter for their future education and exploration, imagination and thereby employment prospects. But creativity to generate knowledge. this leads to a high burden of private The literature indicates that lack of costs for education, including for basic amenities and other school tutoring, with negative consequences inputs including teacher quality are especially for disadvantaged affecting student learning negatively. children. At a minimum, schools should be able to rely on good teachers as well In terms of challenges and related as qualified principals/headmasters, options for policy, the note identifies basic infrastructure, and adequate six priority areas: instructional materials. Beyond broad conditions for learning that 1. Early Childhood Education: must be met in schools, specific The MOETE has already taken interventions can also improve promising strides towards building student performance, such as (1) an enabling environment for Early Pedagogical interventions to improve Childhood Education (ECE).Yet teaching, taking into account student demand for ECE has surpassed needs; (2) sustained teacher training the limited supply available. In associated with a specific method or addition to challenges in access, task; and (3) interventions increasing variation in the quality of service the accountability of schools and delivery exists and is largely teachers to students and their determined by socioeconomic parents. Analysis for Egypt suggests factors.   that gains in these areas could indeed improve student performance. 2. Teacher Policies: The teaching profession in Egypt does not With regard to spending on education, currently attract high performing budget allocations for the education students and it tends to have a sector have increased. However, low status amongst secondary 6 Social Sector Note school graduates. More targeted development process of exams approaches need to be adopted (some of which undergo little towards preparing and then hiring or no item testing) and yet they high performing students who can significantly affect the life chances be great teachers and fill teacher of students by determining their shortages in specialized subjects tracks within schools and career such as math and science. options post-graduation. Changes in teacher professional development practices are 4. Skills Development/TVET: also needed to align classroom There is a weak link between the practices with curriculum reforms. education and training system, Finally, teacher deployment, and the labor market. This incentives and accountability manifests itself as a mismatch also matter. For example, teacher between the skills needed by accountability is weak with little to the job market and what is being no sanctions for poor-performers, produced by the education and thus, creating limited incentives training system. Given such for teachers to perform at high challenges, reform initiatives levels. should take a holistic approach towards skills development. 3. Student Assessments: Overall, student assessments are geared 5. School Autonomy and towards student tracking and not Accountability: Despite a learning. To date, there are no tendency towards centralization nation-wide, comparable data in state affairs, Egypt suffers from available on the quality of learning fragmentation in education policy, outcomes of students, schools, financing and administration, districts, or governorates. which contributes to lack of Assessment and reporting direction at the school level. practices remain focused on Enhanced school autonomy determining whether students together with accountability is are able to recall information important to improve the quality as opposed to their ability to of the education delivered to problem-solve or think analytically. students. High-stakes examinations at Grades 6, 9, and 12 are used 6. Innovative Use of ICT and to track students, as opposed Improved Curriculum, to employing assessments Pedagogy, and Teaching to improve accountability for and Learning Materials and educational outcomes. There are Environments: MOETE has also deficiencies in the design and been expanding access to ICT, 7 Social Sector Note but the sector still struggles with social justice in healthcare and poor technological infrastructure prioritizing areas related to service and limited internet connectivity delivery, financial protection, and in schools. There is a clear quality of care. Thereafter, a number need to expand availability of IT of suggestions for potential policy while ensuring that teachers are options are provided. trained and that the curriculum The note makes the case for the and pedagogical practices foster importance of health by documenting use of ICT and other teaching and benefits from such investments and learning equipment to improve areas where health outcomes in learning. Egypt lag behind other comparable countries. SELECTED ISSUES AND OPTIONS IN THE HEALTH While Egypt is doing relatively well SECTOR on some health indicators, such as This note, the second in the series, maternal mortality, it is doing poorly also has two objectives. The first on many other indicators, including objective is to provide a rapid fertility, under-five mortality, and diagnostic of selected features of the under-five malnutrition, as compared health sector, with a particular focus to other countries. In addition, despite on (1) comparing the performance a recent increase in the budget for the of Egypt on selected health health sector, the public spending for indicators with other countries with health remains below expectations. similar levels of development; (2) The share of spending allocated to analyzing health spending, both by non-labor cost is especially low due the government and households, as to the burden of a high wage bill. well as the implications for quality in delivery and the demand for care; The low public spending along with and (3) emphasizing the importance the fragmented risk pools and lack of programs for early childhood of strategic purchaser shifts leads development. In addition, specific to high financial burden, especially challenges faced by Egypt are for the poor. Private spending for also briefly discussed in the areas healthcare as a share of total health of Hepatitis C and female genital spending is high, with resulting out- circumcision. The second objective of of-pocket costs that represent a the note is to discuss potential policy potentially large financial burden options and specific interventions on individuals and households. The that could be implemented to improve low levels of public spending may health outcomes. This is done first at also lead to low actual or perceived a broad level, building on a recent quality in the care being provided, as study providing a roadmap to achieve the observed low satisfaction rates 8 Social Sector Note for services provided by public health This could be achieved by: facilities suggest. Moreover, the high (i) separating purchasing and out of pocket cost of care as well provision functions; (ii) reforming as concerns for quality may reduce existing payers who provide the demand for care when needed, coverage; (iii) defining and costing leading to no care or self-medications. package of services; (iv) defining In some areas Egypt is facing provider payment mechanisms; challenges peculiar to the country. As and (v) preparing providers for one example of such challenges, the contracting. Additionally, further note includes a discussion of Female financial support should be Genital Circumcision, together considered for those that cannot with some insights from programs afford quality care, or are at risk that have shown promise to curtail of catastrophic health spending the practice in other countries. As another example, the note provides • Improving quality in public a diagnostic on the coverage of facilities in lagging regions by: essential interventions for young (i) training providers in line with new children, noting that coverage often healthcare demands; (ii) attaining remains too low. independent accreditation for The note proposes three main policy public facilities; (iii) scaling up areas aimed at: performance-based financing and incentives; (iv) increasing citizen • Improving outcomes for participation in the service delivery; vulnerable groups through: (v) establishing grievance redress (i) targeted national plans for mechanisms and progressive high-priority health concerns; (ii) legislature; and (vi) shifting to a integrated family health services demand-based model of health model of care with referrals; (iii) budgeting and investment.. monitoring/surveillance of high risk groups; and (iv) interventions for The note also outlines three sets of key risk factors for disadvantaged priorities/programs, namely: Universal groups. Health Coverage (UHC); Prevention, control and treatment of Hepatitis C; • Providing financial protection and Population and early childhood for vulnerable groups. The idea is development. to promote dual coverage through Three sub-programs that could be state funded health coverage relied upon to achieve Universal plans for essential family health Health Coverage (UHC) in a services and through enrollment progressive approach, with each one in Social Health Insurance (SHI) adapted to particular features of the to cover higher levels of service. geographic areas served: 9 Social Sector Note • Progressive Coverage of the For Hepatitis C, three measures are Poor Regions (Upper Egypt proposed: (i) strengthening infection UHC Initiative) by: (i) upgrading control and blood safety; (ii) ensuring supply; (ii) establishing a early detection and reaching more strategic purchaser for family patients; and (iii) treating more health services; (iii) enrolling all patients. citizens based on residence; (iv) As for the third priority, attention guaranteeing financing for primary should be placed on policies and and secondary care; (v) linking programs related to population coverage for tertiary car and and early childhood as follows: (i) catastrophic illness to HIO and selecting priority areas of focus/ PTES; (vi) instituting capitation interventions; and (ii) establishing a and performance payments. multi-sectoral financing facility. • Canal Region Social Health In summary, the note underscores that Insurance Initiative (The Egypt faces major challenges, and in Big Bang Approach) by: (i) many areas may not be performing establishing the legal backbone; as well as one might expect given the (ii) building capacity for health level of economic development of the insurance functions; (iii) unifying country. Of special concern are poor SHI rules and regulations; and (iv) health outcomes for disadvantaged building capacity among providers groups. To ensure the progressive for contracting. realization of universal health coverage and improve outcomes • Social Health Insurance for disadvantaged groups, priorities Transition (Other Regions) by: (i) could include expanding the provision establishing a purchaser-provider of a package of family health split within HIO; (ii) expanding services especially in lagging areas enrollment for the families of HIO and increasing insurance coverage enrollees; (iii) improving enrollment for disadvantaged groups in order of other beneficiaries within HIO; to reduce out of pocket payments. A (iv) decreasing HIO opt-out; range of incentives and trainings for (v) defining provider payment improving the quality of care in public mechanisms within HIO; (vi) facilities could also be provided. upgrading purchasing functions within PTES; (vii) improving SELECTED ISSUES AND beneficiary targeting by PTES; OPTIONS FOR ENDING EARLY (viii)) establishing an independent MARRIAGE accreditation organization; and (ix) boosting provider’s capacity This note, the third in the series, also for quality assurance. has two objectives. The first objective 10 Social Sector Note is to provide a rapid diagnostic of key in this brief suggest that this is the issues related to child marriage. The case in Egypt. Girls who married as note first discusses the trends in child children have on average substantially marriage and in early childbirth, noting lower levels of education attainment. that in Egypt most early childbirths are They have a larger number of related to child marriage. Next, the children over their lifetime, thereby note discusses the negative impact contributing to population growth and of child marriage on development comparatively high rates of fertility in outcomes in five areas: (1) education the country given its level of economic attainment for girls; (2) fertility, (3) child development. Early marriage also health as measured by under-five leads to early childbirth which in turn mortality and malnutrition; (4) labor has negative effects on their children, market participation and earnings leading to higher risks of under-five for girls in adulthood, and finally (5) mortality and stunting, among other various forms of agency as well as risks. Because of lower education well-being. The second objective attainment, a larger number of of the note is to outline the type of children, and additional direct effects programs and policies that could be of early marriage on labor force implemented to end child marriage. participation and earnings levels, This is done first through a rapid early marriage reduces earnings for review of the literature, next through women, and thereby the population an analysis of the steps already as a whole. Finally, early marriage is taken by the government in this related to lower levels of happiness in area, and finally through a typology married life, and leads after controlling of needs and options for programs for a wide range of other variables to depending on the needs of specific a higher probability that mothers will groups of vulnerable girls. The note have their daughters undergo female underscores that child marriage and genital mutilation. early childbirth have large negative impacts and economic costs for the To prevent early marriage and girls marrying early, their children, improve development outcomes for their communities, and society. adolescent girls at risk of marrying Impacts and costs are observed for early, the note outlines five strategies education, health, nutrition, fertility, as follows: work, and earnings among others. • Empowering girls with One in six girls still marry before information, life skills training, and the age of 18 in Egypt. It is often support networks to enhancing argued that early marriage has opportunities for continued serious negative impacts on a girls’ schooling for girls and adopting education. The estimates provided an appropriate legal framework. 11 Social Sector Note • Engaging parents and The government took a major step communities through one- towards ending early marriage on-one meetings with parents, through the adoption of a national community and religious leaders strategy in 2014 for the prevention to gain support; group/community of the practice, aiming to reduce education on consequences of/ the prevalence of early marriage by alternatives to early marriage; and 50 percent within a five year time- public announcement/ pledges by frame. It focuses efforts on areas leaders. within Egypt with the highest rates of early marriage. The strategy • Improving formal schooling has five operational directions: (i) and education opportunities for empowering girls (including economic girls by preparing, training and empowerment); (ii) supporting girls supporting girls for enrolment/ who were married early to minimize re-enrolment in school; raising the negative impacts on them, their the quality of instruction in formal children and families; (iii) completing school to improve learning; and updating legislation to ensure that building schools, improving exiting protections are working in favor facilities and hiring female of girls and women; (iv) empowering, teachers; and providing remedial educating and preparing young girls education including through after- so they can tackle family and societal school programs. pressures; and finally (v) working with families and communities to ensure • Providing incentives and that they understand the harmful economic support by use of consequences of early marriage. incentives to remain in school, such as cash transfers, scholarships, Experience from other countries can fee subsidies, uniforms, supplies; shed light on the types of programs and provision of microfinance and that could help delay early marriage, related training to support income as well as support the needs of girls generation by adolescent girls. still marrying early. One of the basic ideas is to target specific programs • Enacting laws and policies such to the needs of various groups of as legal minimum age of marriage adolescent girls. For girls in school, at 18; advocacy for new policies most parents in many countries regard and enforcement of existing laws/ formal education as an acceptable policies; and raising awareness alternative to early marriage. But about the negative consequences the cost of secondary education (out of early marriage. of pocket and opportunity costs) is high for households in poverty. This suggests the need for programs 12 Social Sector Note to reduce the cost of education for skills, and access to savings groups, disadvantaged girls. In addition, the as well as life skills, including on low quality of education in many knowledge about reproductive health, schools does not encourage parents but in a culturally sensitive manner to to invest in their daughters’ education. promote birth spacing and the use In order to improve school quality, of contraception. More detailed work a focus on basic skills acquisition would be needed for Egypt to assess should be a priority for girls ages 13- whether these policy and program 16 apart from the provision of well suggestions would work, but these targeted transfers or other programs are good starting points to think about to help offset the cost of schooling. potential options. Finally, girls in that group also need life skills training. Similarly, for girls in school ages 1718-, schooling must provide value. This can be achieved by focusing more on preparing girls for formal labor market positions and careers in which the girls can in adulthood serve as models for younger girls. For girls out of school, interventions differ depending on whether they are married or not. For girls not yet married, the key may be to provide a viable alternative to marriage. Programs could focus on building financial literacy, microenterprise skills, enhancing access to savings and expanding economic opportunities. Life skills should also be emphasized, for example through ‘safe space clubs’ together with financial incentives to attend. These programs could look almost like schooling to achieve some of the protective status against early marriage provided by formal education. Finally, for girls already married, programs could also offer financial literacy, microenterprise 13 Social Sector Note KEY MESSAGES: • This note provides a diagnostic of issues faced by the pre-tertiary education sector in the areas of schooling, learning, education and labor market earnings, and education spending. • Acknowledging the Ministry of Education and Technical Education (MOETE) strategy for the sector and the Vision 2030, the note also discusses challenges in six areas: (1) Early childhood education; (2) Teacher policies; (3) Student assessment; (4) TVET/skills development; (5) School autonomy/ accountability; and (6) curriculum, ICT, and materials. Introduction The second objective is to provide a more detailed analysis of This note, the first in a series on specific challenges identified in six the social sectors (see Box 1), has priority areas for the government’s two objectives. The first objective is education strategy: (1) school- to provide a rapid diagnostic of key readiness through expanded and features of the pre-tertiary education targeted provision of Early Childhood sector in the areas of schooling Education programs; (2) evidence- (enrollment, out-of-school children, based pedagogical approaches reasons for dropping out), learning and teacher professionalism; (3) (student performance and factors comprehensive student assessment; affecting performance), education (4) more effective TVET and Skills and labor market earnings , and Development; (5) increased utilization finally education spending, both by of autonomy and accountability the government and by households. towards more effective schools; 15 Social Sector Note and finally (6) innovative curriculum, I. IMPORTANCE OF EDUCATION better learning environment, more effective use of ICT, and improved Globally, the literature highlights teaching and learning materials. a wide range of benefits from education for economic development. Box 1: Series Primer At the individual level, a higher Why a series of notes on the social level of education is known to bring sectors in Egypt? The Ministry of potentially large gains in terms of Finance of Egypt is aiming to improve labor force participation and earnings. outcomes in the social sectors and increase the benefits of public spending A higher level of education may also for the population in order to contribute provide additional benefits related to poverty reduction and development. to the labor market in terms of job This note is part of a series discussing stability and employment benefits. selected issues in the social sectors, For countries, well-functioning especially in health and education. education systems are a necessity to compete globally and ensure that What are the topics discussed in the youth have opportunities to become series? The series focuses on education productive members of society. and health, but considers labor market as well since these outcomes are Education also has large benefits affected by outcomes in education in the areas of health, nutrition, and and health. Special topics are also considered, including early childhood population. It helps, among others, in development and child marriage. The improving maternal and child health analysis is based in large part on recent outcomes, and in reducing fertility household survey data. rates. This in turn generates benefits What is the question asked in this for society as a whole, such as synthesis note? The question is: what reducing pressures from population are some of the challenges faced by growth. Education is also essential the pre-tertiary education sector and for democracy and effective civic potential options to deal with them? participation. While analysis of household and labor force survey How is the question answered? The data suggests that some of these note first provides a rapid diagnostic benefits may be lower in Egypt than of patterns of schooling, learning, education and labor market earnings, in other countries, especially in terms and education spending. The note of labor market outcomes, improving considers next in more details education can also be shown to challenges encountered in six priority be essential for Egypt’s future areas. development. 16 Social Sector Note In Egypt, education is a constitutional stability and supporting growth; (2) commitment and an important priority Improving public service delivery; for the government. As emphasized and (3) Fostering social justice and in Egypt’s Vision 2030, education is inclusion. These broad priorities critical for the country’s sustainable include expanding public spending development. on the health and education sectors in an efficient manner to improve The 2014 Constitution includes a outcomes and quality, taking into commitment to the expansion and account the new Constitutional quality of general and technical and mandate for spending on the social vocational education in line with sectors. international standards. Articles 19 and 20 of the Constitution specify The GOE’s commitment to education a minimum public expenditure on was most recently reaffirmed at a education of four percent of Gross High-Level Ministerial Workshop National Product. The National on Education System Reform Legislature has emphasized the chaired by the Egyptian Ministry of important role that education plays. International Cooperation (MOIC) Policymakers and stakeholders in collaboration with the World have reaffirmed their commitment Bank in April 2016. The workshop to education in recognition of its brought together senior officials role in improving socio-economic from key ministries, international challenges facing the country. organizations, and experts and partners to discuss issues in the GOE’s commitment to education is education sector and successful illustrated by its Vision 2030 and the international good practices. As High-Level Ministerial Workshop a follow up to the workshop, a on Education System Reform detailed matrix of priorities, policies organized in April 2016. and targeted interventions was drafted and submitted to MOIC The Government of Egypt (GOE) and the Ministry of Education and development priorities are spelled Technical Education (MOETE) for out in the Sustainable Development consideration as the platform for Strategy: Egypt’s Vision for the system reform dialogue with the Year 2030 and in the medium-term GOE. It is envisaged that the matrix investment framework presented at would serve as the basis for the the Egypt Economic Development World Bank and other development Conference held in March 2015. partners’ support. The GOE’s objectives and targets can be grouped into three main areas: (1) Restoring macroeconomic 17 Social Sector Note II. RAPID DIAGNOSTIC – Egypt’s education system is SELECTED ISSUES structured according to three main levels. Basic education corresponds This section provides a rapid to children ages 4–14 with two diagnostic of selected issues years of kindergarten followed by six pertaining to the pre-tertiary years of primary school and three education sector in Egypt. The years of preparatory school. At the focus is on the following four topics secondary level, after completion of and related sections: grade 9, some students will pursue • Schooling: the section discusses the general secondary education enrolment rates, attainment, track, while others will enroll in the out-of-school children, and the technical secondary education track. reasons for some students to Contrary to what is observed in many drop out prematurely; other countries, most secondary • Learning: the section discusses school age students follow the the extent to which children are technical track as opposed to the learning in school and some general education track. In some of of the factors affecting student the data presented, especially for performance; international comparison, the general • Education and earnings: the and technical secondary tracks section provides an analysis of the are considered together. Higher marginal benefits from education in education starts in principle as of the labor markets in terms of both the age of 18, although some students likelihood of having earnings and may start later. their levels. It also briefly mentions other benefits from education. More than two thirds of five-year olds • Public and private spending: The are not in school, reflecting a low section looks at trends in public level of enrollment at the preschool spending and the allocation of level. By contrast, in comparison funds, and at the issue of the to other countries with similar high level of private spending, levels of development, Egypt has including for tutoring. relatively high enrollment rates for the primary and secondary levels. (1) Schooling This is visualized in Figures 1 and 2 which display for a large number of Enrollment rates at the primary countries the relationship between the and secondary levels in Egypt are level of GDP per capita of countries at or above expectations given (in logarithm on the horizontal axis, the country’s level of economic using purchasing power parity development, but enrollment at the values in USD dollars) and the gross pre-K level remains too low. enrollment rates for primary and 18 Social Sector Note secondary education (combined economic development. However, secondary and technical) on the enrollment in preschools remains vertical axis. Egypt is identified by the relatively low. red dot in the figures. The trend lines through the scatter plots represent Another way to display the relatively the expected levels of enrollment good performance of Egypt in terms given a country’s level of economic of enrollment rates is in comparison development. Egypt’s performance is to other MENA countries. As shown at or above the expected level given in Figure 3, net enrollment rates in its level of GDP per capita. Egypt are higher than in the MENA region as a whole at the primary Figure 1: Gross Primary Enrollment (%) and secondary level, although not at the tertiary level. In addition, gender parity has been achieved at the primary and secondary levels and there are nine female students for every ten males at the tertiary. These are all important achievements. Figure 3: Egypt’s Net Enrollment Rates in Comparison to the MENA Region Source: Authors, based on World Bank data. and the World (%) Figure 2: Gross Secondary Enrollment (%) Source: UIS data, latest available year (2011– 2013). Egypt still faces challenges as Source: Authors, based on World Bank data. many children of preschool, primary, and preparatory school International comparisons suggest age are out of school or at risk of that primary and secondary dropping out, and many others enrollment rates are at or above do not continue beyond the expectations given Egypt’s level of preparatory level. 19 Social Sector Note In a recent study, UNICEF (2014) Table 1: Out-of-school Children and classifies out-of-school children Children at Risk and children in school but at risk of dropping out into six groups based on education phases, starting from kindergarten (5 years old) to primary schooling (6-11 years old) and preparatory schooling (12-14 years old). Tables 1 provides estimates of the sizes of the various groups and their share in the corresponding population. While the shares of students out-of-school are not very large, at the primary and preparatory level close to one million children are Source: UNICEF (2014). out-of-school or at risk of dropping out. In addition, pre-primary enrollment The share of children not going remains very low, reaching less than beyond preparatory school is much a third of the children. Finally, at higher in the bottom quintiles. As higher levels of schooling (not shown shown in table 2, almost a fourth of in table 1), enrollment is substantially children and youth do not go beyond lower, which is an issue given that the preparatory level nation-wide and the preparatory level is often not the proportion is much higher in the sufficient to get a decent job. bottom quintiles of wealth. One in ten children of primary and Table 2: Highest Education Level for preparatory school age is out of Youth Ages 1821- (% of Youth in Each school. In addition almost a fourth of Category) children and youth do not go beyond the preparatory level. This proportion is much higher in the bottom quintiles of wealth. Source: Authors’ estimation using 2014 SYPE. The main reason cited for dropping out is that children are 20 Social Sector Note not interested in pursuing their As expected, issues of cost are education, which may denote poor much more prevalent for children quality in the education provided. in the bottom quintile of wealth as compared to those in the top Table 3 provides the reasons cited quintile. for why children dropped out, • Lack of parental consent: Parents distinguishing boys and girls, as not being willing to let a child well as children from the bottom two pursue his/her education is quintiles of wealth versus the top also a factor, especially for girls two quintiles. Many findings are as (cited by almost one in five girls expected, but they do suggest the dropping out at the preparatory need for differentiated policies to try level, and almost one in ten at the to reduce drop-outs depending on secondary level). This suggests the group to be targeted. a bias on the part of parents to • Lack of desire to pursue one’s invest more in the education of education: The main reason boys than girls. The bias seems for dropping out is the fact that strong when also considering the children are not interested in fact that girls are subject to early pursuing their education. This may marriage as a separate reason to denote a problem of quality in the drop out. education being provided. This is • Marriage: For girls, marriage observed for both preparatory and accounts for one in ten drop-outs secondary (general and technical at the preparatory level, and 28.1 tracks), and it may denote a lack percent at the secondary level of quality or a mode of instruction (see also Box 3). that is not sufficiently engaging for • Repetitive failure: At the students. At the secondary level, preparatory level, repetitive the fact that students or parents failures are also cited as one consider that the child’s education of the reason for dropping out, is completed is also a key factor, whereas this is less the case at suggesting low expectations or the secondary level. Repetitive perhaps again lack of interest for failure affects especially students additional education. from the bottom quintile of wealth • Cost: Both out-of-pocket costs who may not have the same and opportunity costs (the need ability to pay for private tutoring to help at home, work outside, as children from better off families or help with family work) are the and may also have stronger second largest factor leading to economic pressure to drop out. children dropping out, accounting for about a fourth of the reasons cited for students dropping out. 21 Social Sector Note Box 2: Child Marriage as a Reason to in pursuing their education. This may Drop Out denote a problem of quality in the education being provided. The impact of child marriage on education attainment can be assessed While a detailed analysis of the in two different ways. The first approach programs that could help reduce consists in looking at reasons cited by drop-outs in Egypt is beyond the parents as to why their daughter dropped out or did not transition to the next cycle. scope of this note, it is worth noting This may lead to underestimating the that few households benefit from role of child marriage because other social assistance today according to factors cited by parents for dropping out, data from the 2014 Survey of Young such as a lack of desire on the part of People in Egypt (SYPE)2. This is a child to pursue one’s education, may shown in table 4 which provides the mask a desire or pressure to marry. The share of households benefiting from second approach relies on econometric various forms of social assistance. techniques. Results from the application Normal pensions tend to benefit better of such techniques are discussed in off households, while other forms of another note in this series specifically on transfers tend to reach the poor with child marriage (Wodon et al., 2016a). variables degrees of effectiveness. The reasons mentioned for dropping Conditional cash transfers to improve out suggest that improving learning in education outcomes have increased school could help reduce drop-outs. in recent years. For example, the But in addition, for children and youth Takaful program implemented by from disadvantaged backgrounds, the Ministry of Social Solidarity public cash transfers have proven with support from the World Bank in many countries to help reduce targets 1.5 million households and out-of-pocket schooling expenses consists of conditional cash transfers and reduced the opportunity cost of to promote children’s health care, schooling, thereby leading to higher school enrollment, and attendance. education attainment. Such transfers This expansion of support through (such as the Takaful program) are a well-targeted cash transfers is simple way to provide incentives for welcome to ensure that the poor do school enrollment by offsetting direct have a chance to enroll in school as and opportunity costs and providing well. other benefits for children. The main reason cited for dropping out is that children are not interested 2 More recent data could account for the effect of the new conditional cash transfer program Takaful, although its coverage is still low and geographically concentrated in poorer governorates, mostly in Upper Egypt 22 Social Sector Note Table 3: Reasons for Dropping out by (2) Learning Gender, 2012 Poor learning outcomes are a serious issue in Egypt, threatening the value of the education being provided. In addition to enrollment rates and education attainment, what matters ultimately is how much students learn in school and the relevance of what they learn. Unfortunately, data suggest that half of the children who complete five years of school may not be able to read or write, and 40 percent may not be able to do basic mathematics problems (addition or subtraction). Grade repetition rates are high, with 5.8 percent and 11.2 percent of students, respectively at the primary and preparatory levels repeating a grade. Egypt’s ranking in the Global Competitiveness Index (CGI) remains low (in 2015- 2016, Egypt ranked 116 out of Source: Authors’ estimation using 2012 ELMPS. 140 countries). The poor quality of Note: Values rounding to 0.0 not shown. education is reflected in the country’s Table 4: Share of Households with low ranking on the CGI for education Social Assistance (the country is ranked 139 out of 140 with low ranking on most components of the educational ranking). The performance of Egyptian students on international assessments such as TIMSS is low, especially when factoring in Egypt’s level of economic development. The latest international assessment to which Egypt participated and for Source: Authors’ estimation from 2014 SYPE. which data are available is the Trends 23 Social Sector Note in International Mathematics and Figure 5: Performance on TIMSS Math, Science Study (TIMSS) for the year 2007 2007 (data for 2015 are forthcoming). Figures 4 and 5 show how Egypt compared to other countries that participated in the TIMSS assessment that year. For both science and mathematics, Egypt (identified in green in the Figures, on the bottom left of the set of countries included) has one of the lowest scores among participating countries. The average score for students in eight grade Source: Authors, using data from the TIMSS- was 407.9 for mathematics and Eight-Grade, 2007 391.7 for sciences, well below the Figure 6 shows that in 2007 few international mid-point of 500. The students in Egypt performed at the country was also located within the intermediate performance level or “production frontier” that depicts the higher for mathematics in TIMSS, expected performance of countries and more than half of the students did on the vertical axis as a function not reach the minimum performance of the countries’ level of economic level. Typically, in most countries, development on the horizontal axis. child and family characteristics are Figure 4: Performance on TIMSS more important determinants of Science, 2007 student performance than school characteristics, and this is also the case in Egypt (Assaad et al., 2014; Male and Wodon, 2016). At the same time, there is an important role for “school inputs” to improve student performance, and within school inputs the literature suggests that the quality of teachers is paramount— which could be a contributing factor for Egypt’s poor performance on TIMSS. Source: Authors, using data from the TIMSS- Eight-Grade, 2007 24 Social Sector Note Figure 6: Performance on TIMSS Math, and passing exams and not as 2007 (%) much about learning, with negative consequences. Child, family, and school characteristics all affect students’ performance in school. Among school-level characteristics, the level of resources of schools as well as teacher quality and treatment of children all matter. Analysis of the 2014 SYPE provides Better teaching as well as insights into the factors affecting improvements in other school learning, as measured by students characteristics could improve test scores (recognizing that this student learning. measure has important limits, as just mentioned). The outcome Methods of teaching in Egypt have of interest is the performance of largely focused on rote learning students on examinations. The and memorization of information explanatory variables include instead of promoting critical thinking, child, household, and school level exploration, imagination and variables. Explanations of how some creativity to generate knowledge. of the variables were constructed Success and promotion in the system are provided in Box 3. The detailed is measured through examinations to regression results are provided in test memorized knowledge, and is table 5 where the coefficients can be compounded with early tracking into interpreted as the increase in score technical tracks at grades 6 and 9. associated with various student or Private tutoring is prevalent and should household characteristics as well as be addressed, not only because of school inputs/characteristics. the problematic incentives it creates when the tutors are teachers, but also The following findings emerge from because it often leads to magnifying the analysis, noting that caution inequalities experienced by those should be applied in order not to in lower socio-economic levels. In necessarily interpret correlations as addition, tutoring may also lead to causal effects: absenteeism from school for some • Child characteristics: Girls tend students. An additional challenge to perform better than boys, at is that the education system tends least in primary and preparatory to revolve too much around scores schools. Younger children in each 25 Social Sector Note grade also tend to perform better, preferences and emphasis on probably because older children education (parents sending may have repeated a grade in their children to preschool may previous years, which would be place a higher emphasis on an indicator of lower performance. the education of their children). When children with a disability are Still, the literature does suggest in school, they tend to perform that investing in preschools and less well, but the effects are not more generally in early childhood statistically significant. education pays off; see Box 4). • Location and family • Repetition and tutoring: As characteristics: Controlling for expected, having previously other factors, at the preparatory repeated a grade is correlated level especially, children in with lower performance. As for urban governorates perform tutoring, about half of the students (surprisingly) less well than in primary and preparatory school students in other governorates. are enrolled in after class lessons. The wealth status of the Participating in after school household (quintiles of well- tutoring is associated with higher being) is strongly correlated with scores in the examinations. Again, student performance with better this may reflect the impact of off students having higher test tutoring, or parental preferences scores as expected. Children in and higher investments in their households with many siblings children’s education as is the tend to do less well, possibly case for preschools. because they may receive less • School variables: Somewhat attention individually. By contrast, surprisingly, controlling for the level of education of the father other factors, children in private and mother (again surprisingly) secondary schools tend to does not in most cases have a perform less well than students statistically significant impact on in public secondary schools (at performance, perhaps because least with the data from the 2014 the effect is already captured by SYPE). Students in schools with the quintiles of wealth. more resources (see box 4 on • Preschools/KG: Students who measurement) perform better. went to a preschool perform better. Several variables can be used One should be careful about as proxy for teacher quality and assigning causality however. The the quality of the management of observed effect may reflect the the school. For instance, when impact of preschool in preparing students are always encouraged students for future study, but by teachers to form their own it could also reflect parental opinion, they perform better. 26 Social Sector Note When students feel treated on whether students have special well by the school (see again classes, whether chairs or benches Box 4 for the variables included are broken, whether there are more students on one bench than there in the index), performance in should be, whether lighting in the primary school is better. Finally, classroom inadequate, whether the when students are not satisfied blackboard is in such poor condition about the method for assessing that students cannot see what is learning, performance may be written on it; whether the classroom windows are broken, and whether the lower (here though the direction classroom is adequately ventilated of the effect may be reversed in or not. that the lack of satisfaction may - The index of satisfaction with be due to lower scores). teachers/administrators is based on whether students are satisfied or not Box 3: Constructing Indices for with schooling experience because School Characteristics of treatment from teachers or the administration. - The index about satisfaction with Several indices are used in the regression examinations is related to questions estimates reported in table 19. The as to whether students are satisfied indices are constructed using factorial with their schooling experience in analysis by pooling together answers to terms of the difficulty of the subjects various questions in the survey. being taught, the examinations, or - The index of perceptions of students issues of rote learning. of how well they are treated in school is based on answers to the questions Box 4: Early Childhood Education as to whether teachers/instructors and Development care about the students’ personal problems and help resolve them; whether school social workers care The impact of having been enrolled in about students/teachers problems a preschool on student performance and help resolve them; whether is encouraging, even if the estimates the administration and teachers/ must be taken with caution given instructors treat boys and girls risks of omitted variable bias. Beyond equally; whether the administration preschools, investments in early and teachers treat boys and girls childhood development are essential equally; and whether some teachers/ in order to ensure that children enter instructors beat students and use primary school ready to learn. A separate corporal punishment. note in this series (listed in references) - The index of school resources is based makes the case that investing in young on questions related to whether the school has a library, whether it has children is one of the best investments computers, whether it has a science that countries can make for children’s laboratory, and whether it has a well-being, economic growth and clinic. poverty reduction. Indeed, recent brain - The index related to the state of the research suggests the need for holistic school’s infrastructure is based approaches to learning, growth, and 27 Social Sector Note development, recognizing that young There have been increasing children’s physical and intellectual well- concerns regarding the current being, their socio-emotional and cognitive school curriculum in Egypt and a development, are all related. number of other countries. Curricula are frequently described as (a) being Table 5: Correlates of Student overloaded with information and Performance, 2014 facts that may not be relevant to the needs and interests of students; and (b) lacking a focus on the skills and performance outcomes that are demanded by higher education institutions and by future employers in the labor market. Efforts at improving the curriculum could be based on the premise that a more relevant education will stimulate both student and teacher interest and thus enhance student performance. Skills that could be targeted through curriculum reform include: • Greater student responsibility for their own learning through an increase in independent learning activities. • A greater focus on innovative, experimental, applied and practical work at school. • Development of the research skills of students through the need to find and apply information in pursuit of problem-solving activities. • The development of higher order cognitive skills through an Source: Male and Wodon (2016) using 2014 increased emphasis on critical SYPE. and creative thinking in all subjects at all levels. Finally, changes in the curriculum • Teamwork skills, leadership skills may also bring gains in terms of the based on the capacity to mobilize skills students need to acquire. others, and conflict-resolution and transformation skills. 28 Social Sector Note • Communication skills, which also Analysis of household and labor force includes an emphasis on the survey data across countries suggests development of foreign language that a higher level of education skills and on mastery of oral and often brings important benefits to written Arabic language. individuals and households in many • The use of Information and different ways, including through Communication Technologies the labor markets. Labor market (ICT) as tools in subject learning returns to education in a country and teaching (use basic software are a function of the intersection of applications creatively as part of labor supply (educational attainment the learning process). and achievement) and labor demand • Student and teacher self- from firms. Comparing the returns to assessment. education associated with different • Introducing the modern principles levels of schooling provides an of life-long learning which assessment, albeit limited, of the includes the ability to deal with extent to which different tracks in the ambiguity and to be self-sufficient education system prepare students in institutional settings. for the labor markets. In Egypt, while the benefits from education (3) Labor Market Earnings in the labor market are positive, they are not as large as they should Better educated workers have be in terms of their magnitude (in higher wages, but the returns to comparison to benefits from higher education in Egypt, while positive, levels of education observed in are not high. This may reflect other countries), pointing to the need labor market conditions as well as for raising quality in the education limited quality and learning in the provided. Four different surveys are education system. used here to measure the relationship between education attainment and In a globalizing world, education labor market earnings: the 1998 and skills are becoming increasingly Egypt Labor Market Survey, the important for individuals to obtain 2006 and 2012 Labor Market Panel good jobs and earn decent wages, Surveys, and the 2014 SYPE survey and for countries to compete. This already mentioned. is especially the case in the Middle East and North Africa, a region Table 6 provides data on hourly wages confronted with high unemployment and monthly wages, by education rates for youth and in need of level from three consecutive and improved competitiveness (Islamic comparable labor force surveys Development Bank Group and World for 1998, 2006, and 2012, as well Bank Group, 2015). as the 2014 SYPE survey of youth 29 Social Sector Note (individuals up to 35 years of age). Table 6: Real Wages Discounted for The wage data are in real terms in Inflation, EGP Egyptian pounds of 2012. Better educated workers have in general higher monthly and hourly earnings, even if differences are not large by international standards. For example, in 2012, workers with a higher education have monthly earnings 67 percent above those of workers with less than primary education. For hourly earnings, the gain associated with higher education is 83 percent. In previous years, gains are of a Source: Savadogo and Wodon (2016); Wodon and Yedan (2016). Data sources: 1998 ELMS, similar order of magnitude. After the 20062012- ELMPS; 2014 SYPE. preparatory stage, students pursue their education either in the general Also, while preparatory was secondary track or in the technical associated with a premium versus track. In 1998 and 2006, hourly primary in 1998 and 2006, this was not earnings were substantially higher for the case anymore in 2012, possibly those whom pursued the traditional suggesting that as the population is track, but in 2012, this is not the case getting more educated, preparatory anymore with earnings levels similar may not be sufficient for earning a in the two tracks. premium in the labor market. Note that in 2014 with the SYPE survey, In 2012, workers with a higher real wages appear to be lower than education have monthly earnings in 2012, but this is likely due in large 67 percent above those of workers part to the fact that the sample for the with less than primary education. For 2014 survey consists only of youths hourly earnings, the gain associated only who tend to have lower wages with a higher education is 83 percent. than older individuals. In other words, However, the gains at lower levels of the statistics in table 5 do not imply schooling are not large. an actual broad drop in real wages in 2014. The basic wage statistics in table 6 provide information on the association between an individual’s education level and earnings. This does not imply however causality as other factors may affect earnings. In 30 Social Sector Note order to assess the marginal impact workers for current labor market of education on earnings controlling conditions. for other observable characteristics of the individual, regression analysis Several important findings emerge is needed. Table 7 provides results from the analysis. for the correlates of the logarithm • First, there is some evidence of earnings using both linear (OLS) that a higher level of education regressions and a Heckman model. increases wages. Yet at the same The coefficient estimates are time, the returns are not large interpreted in percentage terms. For by international standards. This example, in OLS model for 1998, a points to the need to improve coefficient of 0.122 indicates that quality in the education being a completed primary education provided, and it may also reflect a generates an earnings gain of about potential oversupply of educated 12.2 percent versus not having workers for current labor market primary education completed. Larger conditions. coefficients indicate larger effects. • Using the labor force surveys, The level of statistical significance there is evidence that the returns for the coefficient estimates is to education may have been also provided. Note that family falling over time, although with connections can be associated with the SYPE survey for youth, this is education and wages (Assaad et not apparently the case. al., 2014). This is controlled for in • Completing preparatory does not the regressions with the labor force bring statistically significant gains surveys through the education of in earnings gains as compared the parents included as independent to completing primary. At least a variables (for the 2014 SYPE survey vocational or secondary degree however, this information is not appears to be needed. available for all workers). Finally, it • Apart from increasing the level is worth mentioning that wages are of earnings, having at least a affected in the public sector by wage- technical or general secondary setting policies for educated workers degree increases the likelihood (Said, 2015). of having earnings. • A number of other effects observed There is some evidence that a better in the regression estimates are education increases wages. At the worth mentioning. Controlling same time, the returns are not large. for other characteristics, women This points to the need to improve earn less than men. Location quality in the education being of the individual also makes provided, and it may also reflect a a difference in earnings, with potential oversupply of educated earnings higher in the Cairo and 31 Social Sector Note Alexandria Governorates than another neglected area, and one elsewhere. Older individuals earn where the intergenerational benefits of as expected more (they have education could be high. As discussed more experience). in more details in a subsequent section of this note, an assessment Table 7: Marginal Impact of Education of workforce development policies on Earnings has been undertaken for Egypt, suggesting areas where policies could be improved. While the analysis in this section has been focused on labor markets, it should also be noted that education for girls brings additional benefits, including through a reduction in women’s fertility over their adult life and lower risk of under-five mortality for children. Better education also Source: Savadogo and Wodon (2016); Wodon increases women’s decision-making and Yedan (2016). in the household, and it reduces the Data sources: 1998 ELMS, 20062012- ELMPS; 2014 SYPE. Statistical significance: *** 1%, ** risk that a daughter will be subjected 5%, * 10%. to female genital mutilation (see Box 5 for a discussion). The relatively low performance of students in school together with a Box 5: Non-monetary Benefits of difficult labor market for youth may be Education part of the reasons why the returns to education appear low in Egypt and Apart from higher wages, education can bring many other benefits, including in the why many students state that they areas of health, nutrition, and population. are not interested in pursuing their Benefits have been estimated using education beyond a certain level. data from the Demographic and Health Egypt’s education system also does Survey (DHS) for 2014. Examples are as not respond well enough to the needs follows: of the job market, contributing together with the weakness of the economy Fertility: Investments in education for to high unemployment rates among girls tend to result in lower fertility (the youths. Given relatively low returns, number of births women have over alternatives such as apprenticeships their lifetime). Each woman gives and other routes to skills acquisition birth on average to 3.5 children. Prior could be considered (Krafft, 2013). to 2008, there had been a 25-year pattern of declining fertility in Egypt, Addressing adult illiteracy is also 32 Social Sector Note but the total fertility rate has recently (FGM). The practice, in turn, has been increased. Reducing fertility would help found to increase risks for children during slow population growth and boost GDP childbirth. It may also lead to serious growth as well as poverty reduction. health complications for women, while Lower fertility would also facilitate service providing no known health benefits. provision by the government among others for basic education, health, and Source: Authors. infrastructure services given the pressure that population growth imposes on public (4) Public and Private Spending resources. Regression estimates for the correlates of fertility suggest that women In terms of budget allocations, with higher education have fewer children efforts have been made in recent than women with primary education or year to increase education lower (the effect for secondary education is not statistically significant versus spending. primary education or less). As shown in Figure 7, budget Under-five mortality: The estimated allocations for the education sector under-five mortality rate was 27 per have increased not only in nominal thousand in the 2014 DHS. This was terms, but also in real terms over the lower than in previous years, but Egypt last five years, despite a more recent continues to have a high rate of under- decrease between 2014 and 2015. five mortality for its level of economic However, Egypt still tends to invest development. Again, regression slightly less in education through estimates for the correlates of under- the budget than other countries with five mortality suggest that children born similar levels of development. In of women with a secondary or higher education are less likely to die before the Figure 8, the relationship between age of five than children whose mother economic development and public has only a primary education or no spending for education is relatively education at all. weak, and multiple factors affect that relationship including the population Women’s agency in the household: A in age of schooling and the market higher level of education leads women share of the private sector. But Figure to have stronger decision-making ability 8 does suggest that overall, public within the household, which in turn has spending for education in Egypt is not been shown in the literature to have on the high side and slightly below benefits for the women themselves as expectations. This may change in well as their children. the future given a newly adopted Female genital circumcision: Women constitutional mandate of spending with a better education are less likely at least three percent of GDP in to have their daughters undergo female education and at least one percent of genital circumcision (FGC) of mutilation GDP in science and technology. 33 Social Sector Note Figure 7: Public Education Budget, contribute to weaknesses in quality 200815-, EGP Mn and lead to pressures for parents to (Left Axis: Nominal; Right Axis: Real) pay for after class tutoring and other programs to help their children to pass examinations that matter for their future education and thereby employment prospects. While the fees paid by households to schools are much lower in public than in private schools, once the tutoring lessons and other expenditures are Source: Compiled by the authors using budget factored in, public schools may not Data. represent such a bargain any more. Because all households do not have Figure 8: Public Spending for Education the same means to pay for tutoring as Share of GDP (%) costs, the system tends to magnify differences in student performance between better off and disadvantaged students that are difficult to address without improving the quality of teaching and educational materials in public schools. In addition, tutoring by teachers, although illegal, continues and may lead to perverse incentives for teachers to teach poorly in class, possibly be absent from school, and remediate the results through profitable tutoring. Source: Authors, based on World Bank data. The burden of private costs for Public spending for education is education, including for tutoring, relatively on the low side in Egypt, is high for households, with putting pressure on households to negative consequences especially complement public education with for disadvantaged children. expensive after class tutoring, which also contribute to inequality in student The private cost of education for performance. households in Egypt is high, with better off households able to spend The fact that enrollment rates are much more than the poor for their relatively high while public funding children to have better education for education is not similarly high may opportunities, including through 34 Social Sector Note tutoring. Figure 9 shows the share of illegal) are critical issues here. total expenditure spent on education Finally, it is worth noting that there is by type of education expenditure also geographic variation in private and by level of economic well-being budget shares spent on education. (quintiles). Overall households Spending shares in urban areas are allocate about five percent of total for example 3.5 percentage points consumption to education, and higher than rural areas, and spending that share is higher for better off shares are almost four times higher households that can afford tutoring in Cairo and Alexandria than is the as well as a private education for case for other governorates. their children if desired. While better off households are able Figure 9: Private Education to allocate a much higher share of Expenditure by quintile their total consumption to education (As Share of Total Expenditure) (and therefore even higher absolute amounts of money), this is not the case for poorer households. Differences in private spending for education, including for tutoring, are likely to magnify inequalities in education outcomes. Box 6: Spending and Education Outcomes Source: Compiled by the authors using HIECS. The literature on education suggests that more spending does not necessarily Said differently, richer households lead to better learning. There are are able to spend more than poorer several reasons for this. First, factors households not only in absolute terms, not related to school inputs, such as but also as a share of consumption, the socio-economic background of which enables better off children to children, often have a stronger impact attend private schools and benefit on how well children lean than school from tutoring lessons. Note that in inputs. In addition, the composition of spending matters at least as much order to address the prevalence of as the level of funding. For example, tutoring, Egypt implemented in-school teacher salaries account for a large help groups, but these may have majority of public education spending. led to additional costs rather than But increasing spending for other inputs lower costs (Sieverding et al., 2016). – including teacher training – can be Implementation and enforcement more efficient to improve learning than (for teachers tutoring is technically raising salaries. Finally, how resources 35 Social Sector Note are allocated between schools, and There may also be issues in terms whether they reach vulnerable children of the allocation of spending that is also important. This matters as gains tends to favor the teacher wage in learning among vulnerable groups bill. from many types of interventions are often larger than for other groups. At As shown in Figure 10, the largest the same time, for schools to function, budgets are needed, and when both part of the public education budget is attainment and learning are taken into allocated to pre-university education, consideration, the relationship between and that share has increased faster costs and performance is stronger. While than allocations for other expenditure. availability of funding does not guarantee Allocating a higher share of total quality education, without adequate spending to pre-university education funding quality education cannot be is appropriate given that much of provided. tertiary education spending benefits better off segments of the population Poor outcomes in some areas, high that can more easily afford the cost out of pocket costs for households of a tertiary education. Unfortunately and quality issues suggest that the government does not provide insufficient fiscal resources comparable data over time in terms of are allocated to the education allocations to the various levels and sector. This tends to be confirmed streams (primary, preparatory, and by a comparative analysis of public general and technical secondary), education spending in Egypt in relative thus preventing an analysis of sub- to levels of spending observed in other sector trends and international countries. Yet it must be emphasized comparisons of such allocations. that simply spending more may not by itself bring the needed Figure 10: Education Budget by Level/ gains in education outcomes. The Function composition, or type and quality, of (EGP Mn, Nominal) public education spending as well as efficiency in spending also matter, and often more than public spending levels. Simply spending more may not bring the gains in education outcomes that are needed. The composition of spending as well as efficiency in spending also matter. Source: Authors, based on budget data. 36 Social Sector Note In terms of equity, it is important to Table 8: Share of Students from Different highlight that public spending for Quintiles by Type of School Attended tertiary education, which may increase Currently/in the Past (%) following the Constitutional mandate, tends to be highly regressive. This is shown in table 8 which shows, by type of provider, that at the post-secondary level a majority of students in public tertiary education institutions come from higher quintiles of wealth and may not need the tertiary education subsidies that are provided by the education system. The benefit incidence of public spending for lower levels of education (as captured by whom attends public schools) is much less skewed towards the better off, as children and youth in lower quintiles of wealth also benefit from Source: Authors using 2014 SYPE and recall public spending. Private schools, as question on the type of school attended. expected, are even more skewed Secondary and vocational combined. towards serving children from higher quintiles of wealth. Figure 12: Education Budget by Economic Classification (EGP Mn, In terms of equity, increasing public Nominal) spending for tertiary education without provisions to target such increases in spending to poorer students would be highly regressive. Source: Authors, based on budget data. Finally, as shown in Figures 12 and 13, and as is the case in other countries, wages are by far the 37 Social Sector Note largest budget item, increasing learning negatively. There has been slightly faster than any other item in a debate about the magnitude of recent years, and thereby crowding those effects. Early studies in the field out other investments—although suggested that family background a more detailed analysis would be and peers had a much larger impact needed to establish patterns and on achievement than school inputs. propose options. Over the last three decades, it has been argued that education Figure 13: Education Budget Shares provision is often inefficient and by Economic Classification (%) that most school inputs make only a small difference for achievement. However, more recently the view that inputs—even as they are typically provided—do not make a difference for learning has been challenged, and many studies suggest they can in fact have an important impacts on outcomes. At a minimum, schools should be able to rely on good teachers as well Source: Authors, based on budget data. as qualified principals/headmasters, basic infrastructure, and adequate III. LESSONS FROM THE instructional materials. Indeed, all LITERATURE ON REFORMS TO three inputs have been associated IMPROVE LEARNING with gains in student learning: • Teachers: Teacher effectiveness, The analysis so far points to an which does not depend primarily issue of quality in the sector. on teacher salaries, is one of the Improving learning in school is most important school-based a priority for the Government. predictors of student learning. International experience suggests Several consecutive years of that different types of reforms outstanding teaching can offset the could yield gains. learning deficits of disadvantaged students. Therefore, as discussed Abrief review of the recent international in a separate note in this series, literature on interventions that may teacher policies (and those improve learning (Wodon, 2016) related to supporting effective suggests that a lack of basic amenities teaching) are one of the most and other school inputs including important ingredients under the teacher quality are affecting student control of schools and Ministries 38 Social Sector Note of Education for student learning. mean that other interventions cannot • School infrastructure: Adequate be successful or are not required— school infrastructure is associated especially in certain country or with better learning. In addition, regional cases—but these were the adequate infrastructure may interventions for which there seemed help in attracting students and to be a consensus across various improving enrollment and it contexts about their effectiveness. makes it easier to recruit and retain teachers and reduce Pedagogical interventions that match absenteeism, which is high in teaching to individual student learning some countries. levels as well as individualized and • School materials and other inputs: repeated teacher training associated Teaching and learning materials, with a specific method or task, including libraries, textbooks, and finally accountability-boosting and where feasible ICT, are also interventions have been shown to essential, and may be more cost improve learning. effective than other inputs to improve learning. Finally, qualified The rationale for the third type of principals are also essential to interventions on accountability stems lead schools. from the idea that they provide a “shorter route” to accountability when Beyond broad conditions for compared to traditional governance learning that must be met in schools, oversight. A simple framework was specific interventions can also proposed on ways to make service improve student performance. In providers more accountable to the a “review of the literature reviews” poor in the 2004 World Development Evans and Popova (2015) suggest Report (World Bank, 2003). Two that three types of interventions routes towards accountability were tend to be recommended across distinguished. The short route runs multiple reviews: (1) Pedagogical directly from users (the children in interventions to improve teaching, school and their parents) to service taking into account student needs; providers (the schools). The long (2) sustained teacher training route is much more indirect because associated with a specific method or users must hold service providers task; and (3) interventions increasing accountable through the state, the accountability of schools and often with little change or success teachers to students and their especially for vulnerable groups. parents. They also list a number of Accountability-boosting interventions specific interventions in each of these such as school-based management three broad areas that have proven reforms aim to give some strength to successful (see table 9). This does not the short route by empowering parents 39 Social Sector Note and communities in the management The magnitude of the gains that of the schools. But it is important to can be achieved, however, will ensure that the risk of elite capture of not necessarily be the same for school-based management reforms all interventions, and therefore is minimized by giving voice and sequencing matters. In a related proper capacity-building support to study, Crouch and DeStefano those who are the most vulnerable in (2015) suggest that there may be a local communities. dichotomy in the size of the gains that can be expected with various Table 9: Interventions with Demonstrated types of reforms and interventions. Impacts They argue that the impact of broad- based reforms and interventions (structural reforms, reforms related to accountability and incentives, and the provision of more inputs) tends to be smaller than that of interventions focusing on pedagogical practices. The impact of broad-based interventions (structural reforms, reforms related to accountability and incentives, and the provision of more inputs) tends to be smaller than that of interventions focusing on pedagogical practices. The types of reforms that these authors have in mind for the various categories are illustrated in table 10. Crouch and DeStefano did not conduct a systematic review, but they Source: Wodon (2016), adapted from Evans considered a number of evaluations and Popova (2015). published in the World Bank Policy Research Working Paper series. Note that the interventions listed in In general, the impact of the broad- table 9 are indicative and listed for based reforms was modest. The reference. They may not necessarily impact of the focused interventions apply to Egypt. For example, was larger. This does not mean supplementing civil service teachers that broad-based reforms are not with locally hired teachers on short- needed – they may be a prerequisite term contracts is very unlikely to be to implement focused pedagogical politically feasible in Egypt. reforms at scale in national education 40 Social Sector Note systems since teachers and schools a larger and also more immediate must be accountable for those impact on student learning. But at reforms to succeed. But it is important the same time, implementing reforms to note that the two types of reforms related to school autonomy and may have impacts of a different order accountability may well be needed of magnitude. for the success of some of the pedagogical reforms. School-based management and accountability reforms may also take more time to bear fruit than reforms focusing on pedagogy. This does not mean again that they are no less important, as mentioned earlier, in part because they may be needed for pedagogical interventions to succeed. Table 10: Differences in Average Impacts for Broad-based and Focused Reforms/ Interventions Source: Wodon (2016), adapted from Crouch and DeStefano (2015). Note: SD = Standard Deviation. One of the conclusions of the rapid review of the literature provided above is that while broad-based reforms are needed in the medium to long term to promote school accountability, pedagogical reforms tend to have 41 Social Sector Note IV. GOVERNMENT PRIORITIES implemented by the Ministry of Industry. In order to improve education 2) Technology Development outcomes for children and youth, Program. An interactive classroom the Ministry of Education and methodology is being applied Technical Education (MOETE) has in nine governorates and will be already identified a number of expanded to all governorates priorities under its new strategy over the next three years. for 20142030-. 3) Primary Education Development Program. The focus of this The MOETE completed its Education program is on mainstreaming Sector Strategy for 20142030-. and expanding the Early Grade The Strategy recognizes the need Learning Program in primary to continue to expand access to school across all governorates. education in the country, but it also This program includes both stresses the need to improve quality reading and mathematics and is through reforms—among others—in being carried out in partnership the areas of curriculum; teacher with the US Agency for policies and school leadership; International Development. and student assessment practices. 4) Children with Special Needs Equity is also of primary concern, Program. Increased support will as the strategy focuses on providing be provided for children with equal opportunities to all students, special needs schools in public including through second chance schools, including through trained programs for out-of-school children cadres and necessary tools, in and those in lagging regions. addition to co-operation with A number of key programs in the new non-governmental organizations strategic plan as well as changes to to provide resource rooms and the Technical Education system are follow-up services for these particularly noteworthy: students. 5) Administrative Development, 1) Technical Education Development Legislation, and Laws Program. Program. This includes the Based on the Education Law initiative of “a factory in each school No. 139 issued in 1981, the and a school in each factory,” as precise roles of the Ministry of well as implementation of the Education and governorates will Egypt-European Union Support be defined. In addition, in light to the Technical and Vocational of the new Egyptian constitution, Education and Training Reform decentralization will be Program in Egypt (Phase II), also implemented more effectively and known as TVET II now being school-based reform enhanced. 42 Social Sector Note 6) Human Resource Management The diagnostic provided in this note Program. Teachers’ salaries were has identified a number of areas raised in January 2014 with a where gains could be achieved. In bonus in return for the agreed job terms of enrollment, while there are workload. This serves to create gaps for children from disadvantaged a positive environment in which socio-economic backgrounds at the school children can develop. primary, preparatory, and secondary 7) Gifted and Talented Sub-program levels, preschools are a priority given of the General Secondary the low enrollment rate currently and Education Program. A unit for the benefits from investments in early science, technology, engineering childhood education. In terms of and mathematics (STEM) learning at the primary, preparatory, schools will be established as and secondary levels, a range part of the Central Administration of issues have been highlighted of Secondary Education of the which have implications for student General Education sector. An achievement as well as the ability for evaluation of existing STEM youth to find employment. schools will be conducted as a basis for future development of Building on the diagnostic provided pre-university education. in this note, the objective in this 8) Primary and Secondary section is not to be prescriptive by Education Programs. The science outlining specific recommendations curriculum in basic education that should be implemented by the will be reformed in light of global government, but rather to provide contemporary trends. more details on some of the specific 9) Human Resource Development challenges faced by the education and Monitoring and Evaluation sector and thereby provide a Programs. The role of inspection foundation for suggested areas for and monitoring bodies at all reforms that could be discussed and levels will be further activated refined as part of the roadmap for the and developed. sector being prepared. V. CHALLENGES IN PRIORITY This section provides an assessment AREAS of challenges in six areas: (1) Early Childhood Education; (2) Teacher A number of challenges faced by policies; (3) Student assessment; (4) the education sector have been TVET and Skills Development; (5) identified as priorities with options School autonomy and accountability; for related policy and intervention- and (6) Innovative Curriculum, ICT, related reforms. and teaching and learning materials. These challenges lead to policy 43 Social Sector Note options that are not meant to be high variation in the quality of facilities prescriptive, but could be discussed with many falling short on hygiene and refined as part of a roadmap for and adequate play space. the education sector. Under the Systems Approach for (1) Early Childhood Education Better Education Results (SABER) program at the World Bank, guidance The MOETE has already taken has been provided on how to assess promising strides towards building country policies in the area of early an enabling environment for Early childhood development, including Childhood Education (ECE). Steps ECE (Neuman and Devercelli, 2013). taken to improve ECE quality include Three policy goals are emphasized: establishing national KG standards • Establishing an Enabling and a series of procedural manuals Environment: this first goal for use by teachers, supervisors, relates to the legal-framework, families, and members of society, as inter-sectoral coordination, and well as offering in-service trainings on finance. It has been estimated the new KG standards, effective ECE that providing ECE access to teaching and supervision strategies 30 percent of young children of and practices, ECE leadership the appropriate age group by standards, and how to conduct 2015 could cost $103 million. community advocacy for ECE. Providing adequate funding for KG12- teachers is a significant However, demand for ECE has challenge despite availability of surpassed the limited supply those teachers in both MOETE available. To address the growing and Ministry of Social Solidarity demands for ECE, the MOETE and (MOSS) KG classrooms. the General Authority for Educational • Implementing widely: this second Buildings (GAEB) have previously goal relates to the scope of completed a detailed school mapping programs, their coverage, and process to identify suitable locations equity in access to existing for new schools or the expansion programs. Despite increasing of existing ones. In addition to demands for ECE services, supply challenges in access, variation is limited and student access is in the quality of service delivery largely determined by wealth, exists and is largely determined by urban location, and gender. Young socioeconomic factors. These are children in the highest wealth illustrated by variations in pedagogy, quintile are almost five times curriculum, and staffing. Challenges more likely to have attended an also persist with shortages in both ECE program in comparison to human and material resources, and children in the bottom quintile of 44 Social Sector Note household wealth. Special efforts Cadre (in 2007); the development need to be undertaken to provide of a career path and a promotional access to ECE for vulnerable system for teachers, along with a groups who also tend to benefit 50 percent increase in basic pay (in the most from such programs. 2007) and bonuses (from 2008). • Monitoring and Assuring Quality: this third goal refers to data More targeted approaches need to be availability on ECE, quality adopted towards preparing and then standards, and compliance with hiring high performing students who standards. While ECE standards can be great teachers and fill teacher exist, they have not yet been shortages in specialized subjects communicated and implemented such as math and science. Hiring across all nurseries and pre- of teachers is ultimately dependent schools. Teacher manuals of on secondary examination results, procedures, standards and since these results filter Faculty of training kits (developed through Education (FOE) applicants and, the National Council of Childhood oftentimes, an oversupply of low and Motherhood) are available performing students is assigned to but not scaled up nationally. the FOEs. In addition, it is important to In addition, only 15 percent of improve accountability mechanisms staff in the field have a higher and incentives to motivate teachers education degree in ECE and to improve their knowledge and more than half only have a high teaching practices, which currently school diploma (data from 2008). remain largely as traditional teacher- Efforts to improve quality through centric methods. Rote learning and data availability on ECE, quality recall of information remain the main standards, and compliance with pedagogical approaches used by standards are recommended. teachers in the classroom. The issue   is further compounded for technical (2) Teacher Policies education staff who lack practical industry experience. The teaching profession in Egypt does not currently attract high Changes in teacher professional performing students and it tends development practices are needed to have a low status amongst to align classroom practices with secondary school graduates. This is curriculum reforms. Currently, pre- the case despite significant efforts service teacher training is limited to to improve the status of teachers, FOEs that themselves are content including the development of National versus practicum focused. As a Standards for Education (in 2003); result, teaching in schools remains the establishment of the Teachers’ outdated in terms of curriculum and 45 Social Sector Note pedagogy. In-service training is incentives and accountability also also proving ineffective in improving matter. Poor planning for teacher teaching and learning practices. It is supply and demand results in the often inconsistent with the realities inefficient and ineffective distribution of the classroom and has not yet of teachers and inadequate targeting evolved beyond traditional methods, of specialized teachers. Likewise, consisting mostly of short, one-off teacher accountability is weak centrally or regionally-based courses with little to no sanctions for poor- of lectures, workshops, seminars, performers, thus, creating limited and qualification programs with little incentives for teachers to perform at or no follow-up. There is insufficient high levels. All of these areas deserve focus on content and subject mastery, focused attention. pedagogy, and student assessment for improved teaching and learning (3) Student Assessments practices. Under the SABER program at the The Professional Academy for World Bank, guidance has also Teachers (PAT) was established in been provided on how to assess 2008 with a mandate that covers country policies in the area of student in-service training and teacher assessment (Clarke, 2012). Four professional development. One of types of student assessments are the functions of the PAT is to set considered, and for each one the standards for pre-service teacher status and challenges of current education and it is meant to accredit practices have been identified in the all teacher education programs and case of Egypt. program providers. Yet, the level of • Classroom Assessments in Egypt collaboration between FOEs and typically measure information the PAT remains sub-optimal, which recall and rather than critical delays reforms in pre-service and thinking. The assessments in-service preparation, training, and tend to rely mainly on multiple- professional development. This choice, selection-type questions. leads to a gap between the rhetoric Student results are rarely used of the new curricular approaches to inform teaching practices and activity-oriented methodologies and are not required to be used enshrined in the National Standards to inform parents about their for Education in Egypt (Ministry of child>s learning. System-level Education, 2003) and the reality mechanisms are needed to of what is actually happening in ensure that teachers develop classrooms and FOEs. the necessary additional skills and expertise in classroom Finally, teacher deployment, assessment. 46 Social Sector Note • Public Examinations in Egypt are to compare the performance high stakes since they determine of students in Egypt to that of students’ future educational students in other countries. It is tracks (tracking into secondary unclear however whether, and education, sorting into higher how, the results are used by education). Performance on these policymakers and stakeholders. exams is largely based on access There are for example no clear to better educational opportunities efforts or policies to ensure that and services, which tends to be ILSA results are disseminated to the advantage of children in to stakeholders at the school, wealthier households3. Scoring district, and governorate levels is often conducted by readers in order to support continuous who have little or no training in improvement plans. As mentioned scoring essays. This can lead to earlier, Egyptian students scored inconsistencies in scores within poorly on TIMSS in 2007, and a cohort and there are limited while TIMSS 2015 results are systematic mechanisms in forthcoming, these results provide place to ensure the quality and policymakers with an important reliability of exams. Few teachers set of data which should inform are involved with item and/or anticipated education reforms. test development, and few exam items are piloted, field tested, or Overall, student assessments are assessed for their difficulty level. geared towards student tracking and • National Large-Scale not student learning. To date, there Assessments (NLSA) in Egypt are no nation-wide, comparable data do not follow a formal policy available on the quality of learning with specified timelines for their outcomes of students, schools, administration, and little effort has districts, or governorates. Current been made to use assessment assessment and reporting practices results to inform policy choices remain focused on determining and teaching and learning whether students are able to recall practices. Mechanisms are in information as opposed to their ability place to ensure the basic quality to problem-solve or think analytically. of the NLSAs, but discrepancies High-stakes examinations at Grades are not required to be recorded 6, 9, and 12 are used to classify and no double scoring/processing and track students, as opposed to of data takes place. employing assessments to improve • International Large Scale accountability for educational Assessments (ILSA) are useful outcomes. There are also deficiencies 3 Better designed exams would help, but not be able by themselves alone to reduce the handicap faced by children from poorer households, since inequality is a systemic problem. 47 Social Sector Note in the design and development towards skills development. Currently, process of many administered there is a lack of leadership and exams (some of which undergo sustained commitment in the sector. little or no item testing) and yet they The country also has no coordinated significantly affect the life chances of TVET strategy, nor is there clear students by determining their tracks alignment between Egypt’s goals within schools and career options and plans for general education and post-graduation. technical education and training. There are also no systematic means Finally, as previously mentioned, early for informing the education and tracking practices are contributing to training systems of Egypt’s changing inequities in the education system labor market conditions. Employers where students from lower socio- appear to have no formal means of economic backgrounds are over influencing education and training represented in the technical education policy considerations. track. Technical and vocational schools are not designed to address Several of these challenges emerged remedial needs the students may from an assessment of workforce have, which may be contributing development (WfD) polices carried to their low performance in exams out for Egypt using the SABER and resulting in their tracking to the WfD assessment tool and finalized technical/vocational stream. Results in 2014. Policies were assessed in this type of examination are strongly along three main dimensions: the linked to educational opportunities strategic framework for WfD, system and the quality of schools attended— oversight, and service delivery (see which students themselves often Tan, 2013 for the conceptualization have little control over—and focus of the framework, and World Bank, on factors that have little to do with 2014, for the tool applied to Egypt). indicators of future performance. • Strategic Framework: There is a lack of fit between what the (4) Skills Development/TVET education system offers and what the job market requires. Such a There is a weak link between the realization is yet to be translated education and training system, and into a clear vision and a strategic the labor market. This manifests itself focus towards youth employability as a mismatch between the skills and lifelong learning. While needed by the job market and what the Egyptian government has is being produced by the education prioritized WfD for the country>s and training system. Given such economic progress, there is challenges, Egypt’s reform initiatives little evidence indicating that should take a holistic approach WfD has been aligned with 48 Social Sector Note economic development plans. state training, with providers The roles and responsibilities of generally conducting relevant key stakeholders in WfD remain and well-structured programs, fragmented, with no visible even though they are offered sector leadership and no unified few incentives to meet quality or agreed vision and strategy. standards and expand their The influence of employers operations. A culture of monitoring and industry in shaping and and evaluation is lacking. implementing WfD priorities is   still limited. (5) School Autonomy and • System Oversight: An Accountability accreditation entity has been established and a number Despite a strong tendency towards of interventions have been centralization in state affairs, conducted on a pilot basis. Yet, Egypt suffers from fragmentation the quality assurance system in education policy, financing and related to WfD (including a administration. The fragmentation national qualifications framework, is both horizontal, across ministerial standards, accreditation, portfolios, and vertical between certification, and assessments) central, governorate and district level lacks coherence, structure, agencies. This fragmentation affects transparency, and consistency decision making, leads to confusion in implementation, and it is not in roles and responsibilities, and based on a well-communicated forces the MOETE to engage in national system. Financial incremental budget negotiations management and results-based with MOF, leading to challenges in funding arrangements are governance and accountability at weak, as evidenced by the lack the central, governorate, and school of connection between public levels. Specifically, enhanced school funding and performance, and autonomy and accountability face a limited private investment. number of challenges: • Service Delivery: Employers • Autonomy: Fragmentation in provide only occasional input policy, finance and administrative into training curricula, and their operations exist with poor influence on the operations of coordination and communication state training institutions is limited. across the responsible entities. Such institutions lack autonomy This is the case for planning and and are not required to meet management of school budgets. specific performance targets. Another issue is the lack of However, there is considerable school autonomy for personnel diversity in the provision of non- management as schools have 49 Social Sector Note no authority in teacher hiring supervisors all have supervisory decisions and principals have responsibilities for teachers on their limited say in dismissal decisions staff. This overlap generates costs and teacher pay. and creates redundancies and • Accountability: Poor performance potential confusion, and constrains persists in teaching and learning the impact and opportunities for practices in schools as teachers improvements. As already mentioned, and principals are subjected to some discretion is given to principals few accountability measures in the in terms of personnel management, absence of an effective school- but this is very limited and does not level accountability framework. apply to important decisions such as Despite weak performance in hiring and sanctioning of teachers. many schools, as illustrated Principals and administrators from among others by grade repetition, idaras and muddiriyas still view their schools are not held accountable roles in terms of inspection rather for results. Finally, while illegal, than supporting and managing for the practice for teachers to results that focus on student learning. engage in tutoring persists. Teachers are therefore less motivated • Information systems: Education to perform at high standards and may Management Information even in some cases have distorted System (EMIS) and other school- incentives to offer poor quality level student performance and teaching in class in order to secure administrative data are not work as private tutors after (and at used systematically to support times during) school hours. decisions at the school level. Improving use of school and (6) Innovative Use of ICT and student assessment data should Improved Curriculum, Pedagogy, thus be a priority, including to and Teaching and Learning inform teacher practices. Materials and Environments In addition, there are also issues of vertical alignment between MOETE has been expanding access the functions and responsibilities to ICT by supplying schools with of the central government, the computer labs, smart boards and governorates (muddiriyas) and the tablets. However, the sector still district administrations (idaras). struggles with poor technological One example is the lack of clarity infrastructure and limited internet on oversight of some of the roles connectivity in schools. Efforts were of school principals, including for previously made at initiating a number teacher supervision. Apart from of activities to generate IT-relevant principals, central MOE supervisors, content for the classroom, but have muddiriya supervisors and idara been done so without a broader 50 Social Sector Note framework of enhanced curriculum faced by the pre-tertiary education development, teacher training, or sector in the areas of schooling, adequate school technological learning, education and labor market infrastructure. earnings, and education spending; and (2) to discuss challenges in six In terms of current access-related priority areas, namely early childhood issues, a number of statistics are education, teacher policies, student revealing: (1) Computer laboratories assessment, technical and vocational are scarce and available in only education and skills development, 12 percent of primary schools, 42 school autonomy and accountability, percent of preparatory schools and and finally the use of ICT and 23 percent of secondary schools; (2) other innovative improvements Fewer than half of Egypt’s educational in curriculum, pedagogy, and institutions have an Internet teaching and learning materials and connection, compared with more than environments. two-thirds in countries such as Oman and Jordan; (3) Although 91 percent The findings in this note demonstrate of computers in primary schools and the importance of investing in 96 percent in preparatory and upper education for development. They secondary schools are devoted to also suggest options for improving learning, computer resources are education outcomes. In terms of greatly overstretched, with 140 students dropping out, cost remains primary pupils sharing a computer an issue for some, as does child on average. There is a clear need marriage for girls. But more importantly, to expand availability of IT equipment the fact that many students are not while ensuring that teachers are interested in pursuing their education trained and that the curriculum and also suggests major issues of quality. pedagogical practices foster use of Proficiency levels on international ICT and other teaching and learning student assessments are low, and equipment to improve learning. students are not learning nearly enough in school. CONCLUSION The literature suggests that both broad-based reforms to promote If Egypt is to achieve further school autonomy and accountability, progress towards poverty reduction and pedagogical reforms to improve and other development goals, teaching and learning are needed. improving education attainment The good news is that the analysis and achievement will be needed. suggests that gains could be achieved This note had two objectives: (1) in student achievement by improving to provide a diagnostic of issues pedagogy in the classroom, among 51 Social Sector Note others, and suggestions are also available to improve workforce development policies as well as broad funding allocations, to mention just some of the topics that were discussed. As mentioned earlier, the challenges and implicit options suggested in this note were not meant to be exhaustive, nor are they meant to be prescriptive. Rather, they are meant to be indicative, and other options could be considered as part of the roadmap that is being prepared for the education sector reform.   52 Social Sector Note References Male, C., and Q. Wodon, 2016, Factors Affecting Student Performance in Assaad, R., C. Krafft, and D. Salehi- Egypt, mimeo, Washington, DC: The Isfahani, 2014, Does the Type of World Bank. Higher Education Affect Labor Market Outcomes? A Comparison of Egypt Neuman, M., and A. Devercelli, and Jordan, Economic Research 2013, What Matters Most for Forum Working Paper Series No. Early Childhood Development: A 826. Cairo, Egypt. Framework Paper, SABER Working paper Series No. 5, Washington, DC: Clarke, M., 2012, What Matters Most The World Bank. for Student Assessment Systems: A Framework Paper, Washington, DC: Said, M., 2015, Wages and Inequality The World Bank. in the Egyptian Labor Market in an Era of Financial Crisis and Revolution, in Crouch, L. and J. DeStefano, 2015, The Egyptian Labor Market in an Era A Practical Approach to In-Country of Revolution, edited by R. Assaad Systems Research, Mimeo, RTI and C. Krafft, Oxford, UK: Oxford International. University Press. Evans, D., and A. Popova, 2015, What Savadogo, A., and Q. Wodon, 2016, Really Works to Improve Learning in Labor Market Benefits from Education Developing Countries? An Analysis in Egypt: Results from Labor Force of Divergent Findings in Systematic Surveys, mimeo, Washington, DC: Reviews, Policy Research Working The World Bank. Paper No. 7203, Washington, DC: The World Bank. Sieverding, M., C. Krafft, and A. Elbadawy. 2016. ‘The Teacher Does Islamic Development Bank Group Not Explain in Class’: An Exploration and World Bank Group, 2015, of the Drivers of Private Tutoring in Education for Competitiveness (E4C): Egypt (Forthcoming), Open Society A Framework for Action, Washington, Working Paper. DC: Islamic Development Bank Group and World Bank Group. Tan, J. P., 2013, What matters for Workforce Development: A Krafft, C., 2013, Is School the Best Framework and Tool for Analysis, Route to Skills? Returns to Vocational SABER Working paper Series No. 6, School and Vocational Skills in Washington, DC: The World Bank. Egypt, Minnesota Population Center Working Paper Series No. 201309-. 53 Social Sector Note UNICEF, 2014, Egypt Country Report on Out-of-school Children, Cairo: UNICEF Middle East and North Africa Regional Office. Wodon, Q., 2016, What Matters Most for Equity and Inclusion in Education Systems: A Framework Paper, SABER Working Paper No. 10, Washington, DC: The World Bank. Wodon, Q., E. Calimoutou, C. Male, M. C. Nguyen, A. Onagoruwa, A. Savadogo, and A. Yedan, 2016, Impact and Cost of Child Marriage for Egypt’s Development, Egypt Social Sector Note, Washington, DC: The World Bank. Wodon, Q., and A. Yedan, 2016, Labor Market Benefits from Education for Egypt’s Youth: Assessments Using the 2014 SYPE survey, mimeo, Washington, DC: The World Bank. This note was prepared by a World Bank team as an input into a technical assistance task for World Bank, 2013, Jobs for Shared Egypt’s Ministry of Finance. Important inputs for Prosperity: Time for Action in the the note as well as comments were provided Middle East and North Africa, by Amira Kazem and Shahram Paksima. Peer Washington, DC: World Bank. review comments were provided by Caroline Krafft and Nistha Sinha, as well as participants at a review meeting for the note are gratefully World Bank, 2014, Arab Republic acknowledged. Support from Gustavo Demarco of Egypt: Workforce Development, for the preparation of the note is gratefully SABER Country Report, Washington, acknowledged. Guidance was provided by DC: The World Bank. Asad Alam and Safaa El Tayeb El-Kogali. The note benefitted from funding from the Global Partnership for Education as part of a global research task on out of school children and disadvantaged groups. The opinions expressed in the notes and related studies are those of the authors only and need not represent the views of the World Bank, its Executive Directors, or the countries they represent. 54 Social Sector Note KEY MESSAGES: • This note provides a diagnostic of selected issues faced by the health sector, including in terms of health outcomes, public and private spending for health, and other challenges. • Acknowledging on-going government efforts to improve health programs and policies, the note also suggests a roadmap to achieve social justice in healthcare, including options for reforms and programs related to service delivery, financial protection, and quality of care. INTRODUCTION of programs for early childhood development. In addition, specific This note, the second in a series on challenges faced by Egypt are the social sectors (see Box 1), has also briefly discussed in the areas two objectives. The first objective is to of Hepatitis C and female genital provide a rapid diagnostic of selected circumcision. features of the health sector, with a particular focus on (1) comparing the The second objective of the note is performance of Egypt on selected to discuss potential policy options health indicators with other countries and specific interventions that could with similar levels of development; be implemented to improve health (2) analyzing health spending, both outcomes. This is done first at a by the government and households, broad level, building on a recent as well as the implications for quality study providing a roadmap to achieve in delivery and the demand for care; social justice in healthcare and and (3) emphasizing the importance prioritizing areas related to service 55 Social Sector Note delivery, financial protection, and I. IMPORTANCE OF HEALTH quality of care. Thereafter, a number of suggestions for potential policy Health outcomes matter by options are provided. themselves, but they are also important for economic growth Box 1: Series Primer and development. Why a series of notes on the social Good health is essential for individual sectors in Egypt? The Ministry of and household well-being. Policies Finance of Egypt is aiming to improve and programs aiming to improve outcomes in the social sectors and health outcomes are invaluable in and increase the benefits of public spending by themselves. But in addition, good for the population in order to contribute to poverty reduction and development. health outcomes also bring economic This note is part of a series discussing benefits, including by ensuring that selected issues in the social sectors, all individuals have the opportunity to especially in health and education. be or become productive members of society. Illnesses and injuries reduce What are the topics discussed in the the ability of individuals to make a series? The series focuses on education decent living, and thereby contribute and health, but considers labor market as to poverty. Without adequate health well since these outcomes are affected insurance, catastrophic health by outcomes in education and health. expenditures can have major and Special topics are also considered, lasting negative effects on individuals including early childhood development and households. Reproductive and child marriage. The analysis is based in large part on recent household health affects population growth and survey data. thereby economic growth per capita as well as public sector outlays, since What is the question asked in this budget requirements increase when synthesis note? The question is: what the population to be served grows. are some of the challenges faced by the Health and demographic outcomes health sector and potential options to also matter for employment patterns, deal with them? especially for youth, and thereby for social harmony in a country. How is the question answered? The note first provides a rapid diagnostic In Egypt, health is a constitutional of selected issues in the health sector. commitment and a priority for the The note considers next in more details challenges encountered in areas such government as emphasized in as service delivery, financial protection, Egypt’s Vision 2030 for the country’s and quality of care. sustainable development. 56 Social Sector Note The right of citizens to health and governance; v) Decentralizing health healthcare is an important priority service provision; vi) Developing IT for the government. This is clearly infrastructure to support healthcare illustrated in key national documents, systems; vii) Developing human programs, and efforts to attain this resource management in the health goal. The 2014 Constitution affirms sector; and viii) Developing the in multiple instances the importance pharmaceutical sector. of health and the right to health of citizens. Article 18 specifies that every Health is a priority sector under the citizen has the right to health and to Constitution and GOE’s commitment comprehensive healthcare which to health is expressed in its Vision complies with quality standards; that 2030. the State shall allocate a percentage of government spending to health GOE’s priorities are also spelled equivalent to at least 3 percent of out in the medium-term investment Gross National Product (GNP), framework presented at the Egypt which shall gradually increase to Economic Development Conference comply with international standards; held in March 2015. The GOE’s and that the State shall establish a objectives and targets can be comprehensive health insurance grouped into three main areas: system covering all diseases for all (1) Restoring macroeconomic Egyptians, and the Law shall regulate stability and supporting growth; (2) citizens' contribution to, or exemption Improving public service delivery; from, its subscriptions based on their and (3) Fostering social justice and income rates. inclusion. These broad priorities include expanding public spending The Government of Egypt (GOE) on the health and education sectors development priorities are spelled in an efficient manner to improve out in the Sustainable Development outcomes and quality, taking into Strategy: Egypt’s Vision for the account the new Constitutional Year 2030. The strategy also mandate for spending on the social emphasizes the role of health as a sectors. critical prerequisite for sustainable development and as an important pillar for the social dimension of the II. RAPID DIAGNOSTIC – strategy. Key Performance Indicators SELECTED ISSUES include i)Adopting inclusive healthcare coverage; ii) Improving the quality This section provides a rapid of healthcare service provision; iii) diagnostic of selected issues Enhancing preventive and health pertaining to the health sector. The programs; iv) Improving health sector aim is not to be comprehensive 57 Social Sector Note and exhaustive, but to identify a for young children. Fertility will also number of salient issues. Five topics be considered given its importance are considered: (1) International for population growth, public service comparisons of health indicators delivery, and poverty reduction. For pertaining to maternal and child each indicator simple cross-country health; (2) Public spending on health; comparisons help in making the case (3) Private spending on health; (4) that while some health indicators Issues related to the quality of care, are relatively good in Egypt, many insurance mechanisms, and their others are poor in comparison to relationship to the demand for care; other countries with similar levels of (4) Issues related to early childhood economic development. development; and (5) Specific health issues for Egypt, including Consider first indicators pertaining Viral C Hepatitis and female genital to women: the maternal mortality circumcision. rate and the fertility rate. Figures 1 and 2 display, respectively, the (1) Benchmarking Health maternal mortality rate and the Indicators Internationally fertility rate across a large number of countries on the vertical axis and While some health indicators are functions of economic development good in Egypt, others are well on the horizontal axis (using the below expectations in comparison logarithm of GDP per capita in US$ to other countries with similar in purchasing power parity terms). economic development levels. Egypt is represented by the red dot. The curves through the scatter plots Many different health indicators could represent the expected values of the be used for benchmarking Egypt indicators given a country’s economic versus other countries. For some development. More complex models indicators, Egypt is an outlier with could be used to assess the expected especially high incidence rates. This values of these health indicators is the case for Hepatitis C and female taking into account a larger set of genital mutilation among others and explanatory factors, but using GDP they will be discussed separately. per capita has the benefit of providing But in order to suggest more broadly a rapid and easily understandable how well Egypt is performing versus benchmark. other countries, it is useful to rely on more commonly used indicators Simple cross-country comparisons such as those for maternal and child suggest that while Egypt is doing health. Therefore we will focus here well for some health indicators such on maternal mortality for women, and as maternal mortality given its level under-five malnutrition and mortality of economic development, it is doing 58 Social Sector Note less well for many other indicators Figure 2: Fertility and GDP per Capita such as fertility, under-five mortality and under-five malnutrition. Figures 1 and 2 suggest that while Egypt is doing comparatively well for maternal mortality (actual value below the expected value), it is doing less well for fertility (actual value above the expected value). In the case of Source: Compiled by the authors using World fertility, the latest Demographic and Bank data. Health Survey (DHS) suggests that each woman gives birth on average Consider next two indicators of child to 3.5 children. After declining for 25 health: under-five mortality and years, fertility is on the rise again malnutrition. As discussed in more from 3.0 births in the 2008 DHS to details in a separate note in this 3.5 births today, with implications for series on investing in early childhood population growth as discussed in a development (listed in references), separate note in this series (listed in Egypt is not doing as well as it should references). on those indicators. The latest DHS suggests that the under-five mortality Figure 1: Maternal Mortality and GDP rate was 27 per thousand births in per Capita 2014. This is lower than ten years ago, but still high in comparison to other countries with similar levels of economic development as shown in Figure 3. Figure 3: Under-five Mortality and GDP per Capita Source: Compiled by the authors using World Bank data. Source: Compiled by the authors using World Bank data. 59 Social Sector Note Child mortality and maternal health malnutrition, Egypt is also below the issues are especially challenging expected value of the indicator for in poorer regions and for the least the country’s level of development advantaged populations (Figure (Figure 5). A child is considered 4) as significant disparities remain stunted if s/he has a height more within the country. Differences than two standard deviations below between the lowest income quintile the median reference height for and the highest income quintile with that age. Stunting often results respect to neonatal mortality, infant from persistent insufficient nutrient mortality and under-five mortality are intake and infections. It may lead to high. Differences are also substantial delayed motor development and poor between regions. For example, cognitive skills that can affect school 83.1 percent of births in rural Upper performance as well as productivity Egypt take place with trained health and earnings later in life. Estimates personnel compared to 97.4 percent from the 2014 DHS suggest that 21 in Urban Governorates. Some 24.1 percent of children under the age of percent of births take place outside of five are stunted. Progress has been health facilities in rural Upper Egypt limited in reducing this rate over the compared to 5 percent in Urban last decade. Governorates. In addition, children under-five in poorer areas are much Figure 5: Under-five Stunting and GDP more likely to die as compared to per Capita their more advantaged peers. Figure 4: Health Outcomes among Income Quintiles Source: Compiled by the authors using World Bank data. (2) Public Spending for Health Public spending for health remains Source: DHS Data. below expectations in Egypt despite recent increase in the health budget. In terms of under-five malnutrition, using stunting as the indicator of Efforts have been made in recent 60 Social Sector Note year to increase health spending. Figure 7: Public Health Spending as As shown in Figure 6, public health Share of GDP budget allocations have increased not only in nominal terms, but also in real terms over the last five years, even if there was a decrease between 2014 and 2015. Figure 6: Public Health Budget, 2008- 2015, EGP Mn (Left Axis: Nominal; Right Axis: Real) Source: Compiled by the authors using World Bank data. As a share of GDP, and as a share of the budget, public spending for health tends to be relatively low in Egypt given the country’s level of economic development. Source: Compiled by the authors using budget In terms of budget shares as well, Data. public spending for health in Egypt is low in comparison to other countries. Nevertheless, spending levels Figure 8 benchmarks Egypt using remain low as a share of GDP, as the logarithm of GDP per capita in shown in Figure 7 where the level current international value (not in of public health spending in Egypt purchasing power parity terms) as is again benchmarked against measure of economic development. other countries with similar levels Egypt is again well below the level of economic development. The of public spending for health as a Figure shows that there isn’t a strong share of the budget in comparison relationship between the level of to other countries at similar levels of economic development of a country economic development. and its share of GDP allocated to health spending. But it also shows that Egypt’s level public spending for health is below expectations. Under the new Constitution adopted in 2014, there is a mandate for increasing health spending to three percent of GDP, up from about 1.4 percent in 2012. 61 Social Sector Note Figure 8: Public Health Spending in the are by far the dominant budget item, Budget, 2010 increasing much faster than any other item in recent years, and thereby likely crowding out other investments. While wages were the main budget category in 2008 with a 44 percent share, the share increased to close to two-thirds of all health spending by 2014. Over the same period, the share of funding allocated to purchases of goods and services fell from 27 percent to 16 percent and capital investment dropped from 18 percent to 13 percent. Subsidies, grants and Source: World Bank (2013). social benefits, some of which may matter for making services affordable Important findings also emerge to the poor, dropped to four percent of from a rapid analysis of trends the budget from six percent. Overall, and allocations in public health the emphasis on wages may have funding. resulted in part from an over-supply of medical staff, especially in some As will be discussed in more details areas of the country. in subsequent sections, apart from poor health outcomes in many areas, Simply spending more may not high out of pocket costs for care and however bring the gains in health quality issues suggest that insufficient outcomes that are needed. The fiscal resource are being allocated composition of public health spending to the health sector. As discussed as well as the efficiency of spending above, this tends to be confirmed by a also matters. Wages are by far the comparative analysis of public health dominant budget item, and have spending in Egypt in comparison increased much faster than other to levels of spending observed in items in recent years, thereby likely other countries, whether as a share crowing out other investments and of GDP or as a share of the budget. weakening overall quality in health Yet simply spending more may not service delivery. bring the gains in health outcomes that are needed. The composition of The pressure for the budget public health spending as well as the generated by an increasing wage bill efficiency of spending also matters. is in part due to a policy of guaranteed employment of healthcare professions As shown in Figures 9 and 10, wages ‘graduates, essentially regardless 62 Social Sector Note of need. The effect of the policy is Figure 9: Health Sector Budget by a wage bill consuming nearly all Economic Classification (EGP Mn, resources and leading to insufficient Nominal) funding for core services, including the much needed operational expenditures which, in theory, should account for a substantial portion of the budget. Nevertheless, much of the discrepancy identified between the wage and operational bills may lie in the huge reliance of the public facilities (hospitals and primary care facilities) on their local-in-house “Service Improvement Funds” that rely heavily on locally generated sources of income rather than getting funds from the general budget. This would suggest that the high wage bill and the employment guarantee Source: Authors, based on budget data. have become constraints for the efficient delivery of quality services Figure 10: Health Sector Budget to the population. As shown in Figure Shares by Economic Classification (%) 10, while spending for wages has increased, other expenditures have been declining. Another trend that has been observed in the budgets of the last few fiscal years was the allocative redundancy of some budget chapters. This is most evident in allocations under chapter 6 (Purchase of non-financial assets- investments) whereby nearly 25-30 percent of the annual allocated funds were not utilized and had to be returned back at the end Source: Authors, based on budget data. of the respective fiscal year. Those available funds could have helped in supporting much needed lines of Large differences in unit costs of expenditure, especially in the much delivery in public facilities seem to needed operational expenses. be observed across governorates. 63 Social Sector Note Additional analysis is needed to look allocation is usually the norm. It is at these patterns in more details, also worth mentioning that except for but they suggest that efficiency a very few localized programs e.g. gains could be achieved through Schistosomiasis and Malaria Control better resource allocations across programs, no allocations based on governorates. the geographic burden of disease were observed. Another issue relates to the allocation of resources to different The data also suggests higher governorates, leading to potentially health expenditure per person large differences in unit costs for in governorates with smaller service delivery. Based on data populations, possibly because of from household surveys on the use smaller economies of scale or to other of public facilities and allocations political factors. While additional to governorates by the Ministry of analysis is needed to look at these Health, preliminary unit costs have patterns in more details, they do been computed for each of the suggest that efficiency gains could governorates. While more data and be achieved through better resource analysis would be needed to ensure allocations across governorates and that the estimation of the unit costs budget chapters, including through by governorate are precise enough, better coordination in budgeting some interesting findings emerge and planning at the national and from the analysis conducted with the governorate level. available data. Governorates with higher GDP per capita generally have (3) Private Spending for Health higher unit costs, which is expected not only because of their higher Low public spending coupled with standard of living, but also possibly fragmented risk pools and lack of a because under the guaranteed strategic purchaser shifts costs to employment of medical graduates households and leads to financial mentioned earlier, and the freedom of burden for the poor. choice of the area in which graduates serve, many graduates tend to go Limited public funding for health may to better off areas, which may be lead to poor quality and/or insufficient contributing to higher unit costs there capacity to provide services. This in despite more visits to health facilities turn may lead to substantial demand in those areas on a per capita basis for privately provided care. A vigorous by the population. However, this private sector is not a drawback, trend is not observed in most vertical as it may introduce competition programs (e.g. vaccinations, family and raise overall quality. Private planning, etc.) where a per-capita providers may have more flexibility 64 Social Sector Note than public providers in managing Figure 11: Private Share of Health health facilities and health workers to Spending, 2010 better serve patients, and they may also be more cost effective. But at the same time, private facilities may require substantial out-of-pocket costs for households, leading to affordability issues that may reduce the demand for care with possibly severe consequences for those not able to afford care. Therefore the public sector must be strong enough to ensure that households who may not be able to afford privately provided services can rely on quality Source: World Bank (2013). care provided in public facilities (or possibly on private facilities but Private spending for healthcare as a in that case typically with public share of total health spending is high private partnerships that ensure that in Egypt, suggesting a potentially affordability of care is achieved). large financial burden of healthcare for households. This is confirmed Both international and national data through patterns of household can be used to assess the private consumption. costs of care for households. In terms of international comparisons, Private health spending may lead probably in part to offset the relatively some households to fall into poverty. low level of public health spending, For example, Rashad and Sharaf private out-of-pocket spending (2015) suggest some households represents a much larger share of become poor due to catastrophic total spending for health in Egypt health costs. Such spending is than in many other countries. This accompanied by the sale of assets, is shown in Figure 11, which displays decreased consumption, and higher private spending for care as a share borrowing to cover medical costs. of total spending on the vertical axis Rural households are more likely as a function of the logarithm of GDP to suffer from catastrophic costs, per capita in current international as are those with an uninsured or value as done in Figure 8. Egypt unemployed head. is well above the level observed in most other countries, including when Data from the 2013 Household taking the level of development of the Income, Expenditure and country into account. Consumption Survey (HIECS) 65 Social Sector Note confirm that most households get some households. As shown in table care from private providers, and that 1, poorer households rely more on out-of-pocket costs of healthcare are public facilities, probably in part due substantial. Summary statistics on to the cost of private care. It can market shares are provided in table 1. be shown that 23 percent of users Private providers account for almost in public health centers come from 85 percent of visits to health facilities, the bottom quintile versus only 11 versus only 11.4 percent for the percent for faith/nonprofit providers public facilities and the rest for faith/ which tend to serve mostly better off nonprofit facilities. One should be households. Still, according to data careful though with these estimates from the 2013 HIECS, even the poor in that other surveys could suggest go to private providers a lot, which a larger market share for public can be costly for them. facilities. There are also differences in the types of facilities used depending Table 2 provides estimates of the on the care needed. Data from the overall funding for healthcare in the 2009/10 Household Health Services country. Public funding is based on Expenditure and Utilization Survey allocations data from the budget, suggest that public facilities have a while private funding is based on larger role for inpatient care while data from the 2013 HIECS survey. private facilities lead in outpatient Of course, public spending is in fact care. Faith/nonprofit facilities tend to a form of private spending as well play a less important role. since public funding is funded for the most part by taxes. Still, it is useful Table 1: Comparative Market Share to note that about two thirds of total of Public, Private, and Faith/nonprofit spending for health is through out-of- Health Providers, 2012-13 pocket cost, while the public budget accounts for only one third of total outlays. Table 2: Public and Private Spending for Health Source: Authors’ estimation using 2013 HIECS. The fact that private facilities play such a large role in Egypt may have both beneficial and detrimental effects. On the positive side, through competition, private facilities may lead to higher quality. But they may Source: Compiled by the authors. also lead to affordability issues for 66 Social Sector Note The reliance on private providers leads households to spend a substantial share of total consumption on healthcare. As shown in table 3, average health spending accounts Source: Authors’ estimation using 2013 HIECS. for 8.5 percent of total household expenditure in the HIECS survey. (4) Quality, Insurance, and Hospital care accounts for the Demand for Care largest expenditure share, followed by products (including medicine) and Low levels of public spending for the cost of outpatient care. While the health contribute to low perceived poor spend a smaller share of their quality in the care being provided. budget on health, for them those costs are likely to be much more Data are also available in national difficult to afford than for the better surveys on perceptions of the off, as mentioned earlier. It is also quality of various health providers. worth noting that while there are few Satisfaction is generally lowest for differences between urban and rural public facilities, as shown in Figure areas in spending shares, there are 12 which displays the share of differences by governorate, with the households fully satisfied with the shares of private expenditures on care they received by type of facility. health in total household consumption The data are summarized by broad ranging from four percent in two type of facility in table 4, comparing governorates to more than 10 percent public facilities with private and faith/ in five. Further, it is interesting to note nonprofit providers. that nearly 21 percent of all out of pocket expenditures on health were The lowest satisfaction rates for spent inside public facilities implying services provided by health facilities that frequenting public facilities tend to be observed for public does come at a considerable cost facilities. to the patients. Finally, it can also be shown that households relying mainly on private providers spend a higher share of their consumption on health than those relying primarily on public providers. Table 3: Private Healthcare Spending as Share of Household Total Consumption (%) 67 Social Sector Note Figure 12: Share of Patients Fully The health system has a limited Satisfied with the Care Received by ability to cross subsidize risks across Type of Facility (%) population groups. For example, the HIO covers formal employees working in either in the public or private sector but not their families. The HIO also covers under different pools categorical such female- headed households and farmers or by age such as children under-five and school children. A program for the treatment on the expense Source: Authors’ estimates using national of state cover mainly selected survey. secondary and tertiary care services for informal workers and the poor. Table 4: Satisfaction Level with Another program for health coverage Facilities, 200910/ for the poor was recently established to cover primary health care and secondary care. Accordingly, the poor in the informal sector do not Source: Authors’ estimation using 200910/ have full coverage but typically can HHUES for non-chronic illnesses and related be covered through services provided visits to health facilities. through the Ministry of Health. Figure Rates of satisfaction are higher in 13 illustrates the complex healthcare urban than in rural areas. The most fund chain currently present in common reason for satisfaction is Egypt. the ease of access of a facility, which Figure 13: Current Healthcare Fund- is hardly an indicator of quality of Chain in Egypt care. By contrast, the main reasons for lack of satisfaction include a lack of provider, followed by high cost (mostly for consultation, but also for medicines), the fact that there are no providers of the same sex as the patient seeking care, the fact that the facility may not be clean, among others. The fact that the coverage and Source: Hamed (2016). risk pools of the health system are fragmented is also an issue. 68 Social Sector Note Among those not seeking care when episodes, but not necessarily for ill or injured, many rely on self- serious conditions. The proportion medication. This may be appropriate is lower for dental issues where self- for minor episodes, but not for serious medication is much less likely to be conditions. Cost is also an issue successful to treat symptoms. In for some, especially among poorer addition, for seven percent of rural households. and 12 percent of urban respondents, the reason for not seeking care is High out-of-pocket cost and cost, with cost much more likely to be concerns for quality may reduce mentioned in lower quintiles of well- the demand for professional care being. Cost is also mentioned more when needed. often for dental issues. A proportion of about five percent cited as a reason Data from the latest national for not seeking care may appear to household health survey for be low, but if one excludes those 2009/ 2010 provide information on declaring that care was not needed the reasons for not seeking facilities- as well as those relying on traditional based care. Summary statistics treatments as well as self-medication are provided in table 5 for rural and possibly because the ailments also urban areas as well as by welfare did not require a consultation, then quintile. This is done for all diseases the share of those not seeking care as well as separately for non-chronic because of cost becomes much diseases, chronic diseases, and more prominent. In addition, the dental issues. When considering all proportion of households citing costs disease types together, almost two as a constraint to seeking care is thirds of those not seeking care use much higher in the bottom quintiles treatment without a consultation or of the distribution of household rely on traditional modes of treatment. consumption. This may be appropriate for minor Table 5: Reasons for Not Seeking Care When Ill or Injured, 2009 (%) 69 Social Sector Note Source: Authors using 2009 HHUES data. Values rounding to 0.0 not shown. (5) Early Childhood Development in young children are substantial, particularly when compared to Investments in early childhood investments made at later stages in development provide unique life. By contrast, failure to invest can opportunities to address inequality, lead to long-term and irreversible break the cycle of poverty, and costs not only for individuals and their improve of outcomes later in life. families, but also for communities and society at large. Gaps in ECD may The early childhood development jeopardize a child’s capacity to reach (ECD) period refers for the purpose of important milestones and achieve this note to the time from conception full potential in life. Programs that until entry in primary school. Health combine services (such as nutrition interventions are especially critical and psychosocial stimulation) can during those years. To fully benefit have especially large beneficial from opportunities later in life, by impacts. Unfortunately, most the end of early childhood, young countries fall short in their delivery of children should be healthy and well- essential services for young children nourished, securely attached to and their families, and this is also the caregivers, able to interact positively case in Egypt. with families, teachers and peers, able to communicate, and ready to A number of essential interventions learn throughout primary school. for young children have been proven to have beneficial There is an emerging consensus that impacts. ECD should be a priority in the social sectors. Returns on investments 70 Social Sector Note The literature suggests a number of women who have completed at least interventions that can be implemented secondary education, and access by governments to enable all to healthcare services, coverage is children to reach their full potential. lower. Denboba et al. (2014) identify 25 key interventions for ECD. Many of Some 60 percent of mothers are these interventions are related to experiencing at least one problem in health. In terms of time periods or accessing healthcare, and the most the age of children, the interventions frequent barriers women reported can be grouped into five packages: were concerns about a lack of drugs the pregnancy, birth, child health and (54 percent) and the availability of a development, preschool, and family health provider (48 percent). When support packages. it comes to the health insurance coverage for women, less than one in Based on a review of the literature, 10 women age 15 to 29 are covered 25 key interventions for ECD are by any type of insurance. Among identified. In Egypt, information is those who were insured, most offered available from recent surveys on the health insurance by an employer or coverage of 20 of the 25 interventions. the General Insurance Agency. The In some cases the coverage of key coverage of conditional cash transfer interventions is high, but in other programs is also low. On average, cases, it remains too low. less than 15 percent of families are offered conditional cash transfers or This section reviews data on the scholarships for students. coverage of these interventions in Egypt. Data from recent household Table 6: Coverage of Essential ECD surveys are available on the coverage Interventions in the Family Support of eight of the 12 interventions in the Package (%) family support package. As shown in table 6, for some interventions, coverage is high, at above or around 90 percent nationally. This is the case for access to improved drinking water and sanitation facility, mother living in households with iodized salt, hand washing facility observed with soap and water. But for other interventions, especially key support for mothers, including the share of women having health insurance, vitamin A supplement for mothers, the share of 71 Social Sector Note Source: Authors using Egypt DHS 2014 Table 8 provides data on coverage of the interventions included in the child Source: Authors using Egypt DHS and HIECS health and development package. data. For relatively simple interventions Notes: Secondary completion indicates women such as immunizations, coverage is age 22-36 years completed 6 years at the high, at above 90 percent nationally. secondary level. Adequate treatment for acute The lowest coverage rate is for respiratory infection (ARI) includes the provision of antibiotic for children with ARI symptoms deworming medication for children (which may not be as important in Data are available on the coverage Egypt as it is in other countries), of five of the six interventions in vitamin A supplements, and children the pregnancy and birth package fed with all 3 infant and young child (table 7). Coverage tends to be feeding (IYCF) practices, at less than higher for birth registration, skilled a quarter of children being covered. attendance at delivery and mothers Table 8: Coverage of Essential ECD who have had regular antenatal care Interventions in the Child Health and during pregnancy, reaching almost Development Package (%) 100 percent in the case of birth registration. The lowest coverage rates are for breastfeeding within the first one hour of birth and iron supplementation for mothers. With regard to iron supplementation during pregnancy, approximately two-thirds of women reported taking iron tablets or syrup during the pregnancy and one-third took iron supplements for 90 days or more. Table 7: Coverage of Essential ECD Source: Authors using Egypt DHS data. Note: DPT = diphtheria, pertussis, and tetanus. Interventions in the Pregnancy and Appropriate infant and young child feeding Birth Packages (%) (IYCF) practices include the timely initiation of feeding solid/semi-solid foods from age six months and increasing the amount of foods and frequency of feeding as the child gets older while maintaining frequent breastfeeding. 72 Social Sector Note Guidelines have been established with respect Table 9: Coverage of ECD Interventions to appropriate infant and young child feeding in the Preschool Package (%) (IYCF) practices for children age 6-23 months (PAHO/WHO 2003 and WHO 2005). Table 9 provides the data on coverage levels for the two interventions included in the preschool and learning package. Nearly two-thirds of children ages three to five years have Source: Authors using Egypt DHS and HIECS benefitted from some form of early data. child care and education program, Notes: The net attendance ratio (NAR) is an and almost half of the children in indicator of participation in schooling among those of official school age (6-11 years). The the target age group were enrolled gross attendance ratio (GAR) is an indicator of at some point in a nursery school, participation in schooling among those of any kindergarten, or other program that age, expressed as a percentage of the official could help children be prepared for school age population. The difference between the ratios indicates the incidence of overage primary school. However, only a small and underage attendance. proportion of five- to six-year-olds are in preschools. Note that estimates To summarize, strengthening of this proportion of children ages interventions for young children is five enrolled in preschools depend one of the best policies that countries on the survey used. Apart from can make. Specific interventions increasing enrolment, it is essential can be recommended based on a to ensure that preschool programs review of the literature. For some are of sufficient quality. Additional interventions coverage rates are discussion of the importance of early good, but for others, coverage childhood education is available in a remains too low. Funding to expand separate note in this series focusing the coverage of the interventions that on the education sector (Wodon have low coverage today should be et al., 2016b). When it comes to considered. continuity to primary education, net enrollment rates in elementary school (5) Selected Challenges Peculiar are relatively high, at 92.4 percent, to Egypt but some children still do not enroll or rapidly drop out (see also Wodon Egypt has the highest HCV infection et al., 2016b). incidence and prevalence rates in the world at about 1 percent and 7 percent respectively of its adult population; the latter is going up to 15 percent in some geographic areas. 73 Social Sector Note Close to 70 percent of new infections prevention, care and treatment of occur in persons less than 25 years viral hepatitis, efforts are fragmented of age. Over 6.5 million people ages across sectors, and a number of key 15-59 years are chronically infected, elements are not fully included such with an estimated 170,000 new as outreach interventions in terms people infected annually and 40,000 of screening and early detection of related deaths per year. Groups cases; follow up on treatment received with higher prevalence rates include by patients; targeting and identifying lower educated populations, rural the poor; infection control measures populations, low income groups, and at all level of care; and pooling of men. The main reasons behind such public and civil society resources for high incidence and prevalence rates treatment. is iatrogenic; going back to unsafe therapeutic injections of parenteral Figure 14: HCV prevalence by age anti-parasitic drugs use with groups, Egypt 2014 reusable glass syringes to control the schistosomiasis and later on, bad infection control practices in health care facilities, public and private alike, coupled with suboptimal screening for transfused blood. Interestingly, despite the drop in the national prevalence rates of viral C hepatitis between the 2008 and 2014 DHS especially in the heavily infected areas Source: DHS data. in Lower Egypt (Delta) region, some Some pervasive cultural practices of Upper Egypt governorates have also have major health risks. shown a reverse trend of increasing This is the case of female genital prevalence rates of the disease (for circumcision which remains highly example in Aswan). prevalent in Egypt. Further, cirrhosis from hepatitis B and C is ten times higher more likely than The international community uses the in comparable countries. Comparing term female genital mutilation (FGM), Egypt with similar countries based on but in the Middle East the term the Global Burden of Disease regional circumcision (FGC) is more often used, classifications, trade partnerships, hence this is the term used here. Data and income classifications, hepatitis from the 2014 DHS suggest that FGC B and C are much more significant remains practice on an overwhelming causes of mortality for men in Egypt majority of women in Egypt (see table than in other countries. Although the 10). A majority of married women MOHP has a plan of action for the believe that the practice is a religious 74 Social Sector Note requirement even though it has been Table 11: Perceptions Regarding FGC, convincingly argued that it is not by 2014 SPE Egypt’s Administrative Court and Alazhar institution (the highest Islamic theological reference) on the basis of their interpretation of Shari’a laws. Less than a third of married women aged 15-49 believe that the practice should be stopped even if more than half understand that it could lead to death in case of complications. Finally, about half of married women believe that men prefer the practice Source: Authors’ estimation. to continue, and only a third recently heard information about the practice. On some of the health issues peculiar to Egypt, international Most women in Egypt are subjected evidence suggests policies that to FGC. A majority believe that the could be promising. This can be practice is a religious requirement. illustrated in the case of FGC. Less than a third of married women ages 1549- believe that the practice Policy responses to the persistence should be stopped even though a of FGC need to be multifaceted, majority understands that it could with health personnel playing an lead to death. important role. According to data from the 2014 DHS, the percentage Table 10: Perceptions Regarding FGC, of circumcisions carried out by 2014 DHS medical personnel (doctor, nurse or other health worker) was 38 percent among respondents (the mothers) versus 82 percent among their daughters. This suggests that FGC is being medicalized, possibly Source: Authors’ estimation. creating additional legitimacy for FGC. This medicalization is due in These perceptions are confirmed part due to the perceived safety of with data from the 2014 survey of health professionals performing the young people in Egypt, as shown in procedure rather than traditional table 11. The data suggest that even practitioners as in the past with among younger groups of women, attendant risk/complications. A support for the practice remains very problematic structure of incentives widespread. is probably at fault when doctors 75 Social Sector Note performing an FGC may be earning health issue. Some interventions in more than from a regular doctor’s Egypt itself have shown some level visit. Possibly financial incentives not of success. For example, a 2011 to carry out the procedure could be evaluation of the FGC-Free Village implemented in order to help end the Model indicated that the program practice. was successful in changing views and attitudes towards FGC. The Including proper training about FGC evaluation emphasized the role in the medical and nursing curricula of mass media and the need to is also important in order to make engage men and religious leaders. sure that healthcare providers do not It cautioned against simply focusing consider FGC as medically indicated on the physical consequences of the for most women or harmless. Medical practice as this could simply lead to students must be made keenly medicalization. Fundamentally, FGC aware of risks associated with FGC. remains prevalent in societies with Information campaigns must also be pronounced gender inequalities and targeted at the population itself. In power imbalances and cannot be Nigeria a MOH campaign instructing ended without ensuring women’s government health facilities to empowerment. educate all women receiving prenatal or postpartum care about the harmful Box 2: Early marriage and Health effects of FGC has been credited with Outcomes a reduction in the practice. While FGC was chosen to illustrate some Due to their sensitivity and of the more specific recommendations that could be made in order to deal with complexity, practices such as FGC particular health challenges confronted must be countered with multi-sectoral by Egypt, another issue that warrants engagements and the combined attention is that of early marriage. As efforts not only from ministries (health, discussed in a separate note in this series women’s affairs and education), but (Wodon et al., 2016a), early marriage can also civil society. be shown to have large negative effects for the health of girls who marry early, as More generally, due to their well as that of their children. Readers sensitivity and complexity, practices interested in the issue may consult the such as FGC must be countered early marriage note in this series (listed with multi-sectoral engagements and in references). the combined efforts not only from In part as a result of all the factors ministries (health, women’s affairs discussed above, gains in life and education), but also civil society. expectancy are falling behind in Ideally FGC should be treated as a Egypt in comparison to global human rights issue and not simply a trends. 76 Social Sector Note Life Expectancy has slightly fallen whereby three distinct independent below global levels. In 2013, the organizations will emerge as the Egyptian’s life expectancy at birth result of the reform: the healthcare was 68.3 years for males and 73.6 insurer (payer), a public organization years for females, increasing from that would supervise all public 1990 levels of 62.4 years for males providers of healthcare services in and 67.7 for females. But gains in life the country (provider), and lastly a expectancy have now slightly fallen quality assurance and accreditation below global gains, in part due to organization tasked with validation changes in the burden of disease, and accreditation of services at the plateauing basic health indicators, national level. The new system will be inequitable health outcomes, a rolled out gradually on a geographic reverse in the trend for the total basis over a number of years with fertility rate, and continued concern the Suez-Canal region governorates with malnutrition. having a head-start. III. GOVERNMENT PRIORITIES Acknowledging the fact that implementing SHI might take a In order to improve health long time, the Government of Egypt outcomes for the population, a (GOE) has embarked on a number of number of programs and policies reforms in the health sector aiming at have already been adopted and in improving equity for disadvantaged some cases put in place. groups among the population. Those reforms include the progressive In order to guarantee access to enrollment of certain disadvantaged care and provide better protection population categories to the current for households against health care Health Insurance Organization costs, Egypt has adopted the path of (HIO). These categories include for Social Health Insurance (SHI) as the example female headed households means to gradually achieve Universal and rural farmers. In addition, a Health Coverage (UHC) and achieve dedicated program (Healthcare equity to its citizens. A dedicated Treatment to the Poor) to cover those multi-disciplinary committee has who remain unregistered under the been tasked to develop the required non-contributory pension system is law and transition plan, and to lay the dedicated to the poorest with health ground for the preparatory work of services at public primary, secondary the new system. SHI is being built on and tertiary providers of care being the concepts of universality, financial made available free of charge. The solidarity (rich to poor, healthy to ill new system has been rolled out and working age to extremes of age), in early 2015 and is expected to and total separation of functions cover nearly 7 million families at its 77 Social Sector Note peak. Finally, the government has main strategic objectives and policy introduced health measures under options suggested by the study. its conditional cash transfer program (Takaful program implemented by (1) Strategic Objectives the Ministry of Social Solidarity with support from the World Bank). The The study on social justice in program is expected to help tackle healthcare emphasized three important health issues within the strategic objectives that the health most impoverished segments, system should aim to achieve (see especially when it comes to nutritional table 12): (1) Improving health issues. outcomes for disadvantaged groups; (2) Increasing financial protection The government has also committed for disadvantaged groups; and (3) itself towards improving the Improving the quality of healthcare functionality and quality of services delivery in public facilities. Next, offered throughout public providers. eleven challenges (listed in table This effort aims at reviving the defunct 8) were identified as priorities to be family health model, referral systems, addressed. The study provided an horizontal integration between assessment of each challenge, as different vertical programs and finally well as policy recommendations improving the grievance redress which will be discussed in the second mechanisms and empowering citizen part of this note. feedback. This is especially evident in the poorest areas in rural Upper For better and more equitable Egypt. A World Bank operation of US$ health outcomes, the health system 75million is supporting this effort. should target three main objectives: (1) Improving health outcomes for IV. SOCIAL JUSTICE IN HEALTH disadvantaged groups; (2) Increasing CARE financial protection for disadvantaged groups; and (3) Improving quality A recent study on social justice in healthcare delivery in public in healthcare identifies several facilities. issues and potential options to resolve them. Table 12: Challenges in Egypt’s Health System The study laid out a roadmap to achieve social justice in healthcare by prioritizing areas related to service delivery, financial protection, and quality of care (World Bank, 2015). This section summarizes the 78 Social Sector Note 14 recommendations organized according to the three objectives mentioned in the first part of this note (table 13). While readers are referred to the detailed study for a full account of the recommendations made, and while many of the recommendations go beyond the simple analysis provided in the first part of this note, it seems worthwhile Source: World Bank (2015). in this section to briefly summarize these recommendations according This note builds on this previous World to the three objectives listed in Bank study and takes advantage of table 12: the fact that the study is available • Improving outcomes for vulnerable to focus on a subset of issues. This groups; means that the coverage of the • Providing financial protection for issues is not exhaustive for the health vulnerable groups; and sector as a whole. For example, the • Improving healthcare quality in challenges of substance abuse and public facilities. mental health are not discussed here since they are well documented in Table 13: Policy Options for Egypt’s the roadmap study for social justice in Health System health. In other words, the discussion in the first part of this note focuses on just a few selected topics. Given broad-based recommendations made in a recent study on social justice in healthcare, this note emphasizes three major policy areas for attention. Many of the challenges outlined in the first part of this note are experienced primarily by disadvantaged groups. In order to improve health outcomes and achieve social justice in the healthcare system, the World Bank Source: World Bank (2015). (2015) study suggested the adoption of a multi-pronged approach with 79 Social Sector Note (2) Improving Outcomes for up-to-date estimates of baseline Vulnerable Groups disease prevalence and changing trends need to be prepared The first four recommendations would for vulnerable subgroups. This aim to improve health outcomes should include a perinatal and for disadvantaged groups. Four neonatal surveillance system recommendations are made. for maternal deaths as well as • Targeted national plans for high- monitoring of NCDs, nutrition, priority health concerns: Such mental health, and disabilities, plans would help prioritize key among other (in the latter case health challenges with a focus through the creation of a national on disadvantaged groups. This registry of disabled persons). would apply for example (and • Interventions for key risk factors among others) to the National for disadvantaged groups: Acceleration Plan for Child and Examples of such interventions Maternal Health or the Plan of include targeted healthcare Action for the Prevention, Care demand creation through and Treatment of Viral Hepatitis. female community workers • Integrated family health services and vouchers for family health model of care with referrals: The services or conditional cash package should: (i) include cost- transfer schemes for nutrition; effective interventions related to awareness campaigns around maternal health; family planning FGM/C, disabilities, mental and reproductive health, including health, and addiction; promotion nutrition and management of of physical activity and good sexually-transmitted diseases; nutrition, including exclusive child health and immunizations; breastfeeding; and a range of outpatient management of other specific interventions, some diabetes, hypertension, and of which are also discussed in a cardiovascular disease; and separate note on early childhood tuberculosis treatment; (ii) be development in this series. linked to public health programs for critical diseases like Hepatitis (3) Providing Financial Protection C and NCDs; and (iii) be linked for Vulnerable Groups to higher level of care through referrals. This would result in a The second set of recommendations revision of the expanded primary aim to increase financial protection healthcare service delivery model for disadvantaged groups, so that currently in existence: households do not fall into poverty • Monitoring and surveillance of due to catastrophic health events high-risk groups: Reliable and and can afford the care they need. 80 Social Sector Note The idea is to promote dual coverage to inform and obtain allocations through: (i) state funded health from the Ministry of Finance. coverage plans for essential family • Defining provider payment health services; and (ii) enrollment mechanisms: The idea is to first in social health insurance (SHI) to cover fixed costs of operations cover higher levels of service. Five for the providers of the package recommendations are made. of family health services with complementary pay-for- • Separating purchasing and performance scheme to finance provision functions: The World variable costs based on volume, Bank study recommended to quality, and incurred hardship for separate the internal payment and services provided. provision functions of the Health • Preparing providers for Insurance Organization. The idea contracting: Given their historical is for the “Payer” division would reliance on line item budgeting, assume the roles of contributions self-generated revenues, and less management, provider attention to efficiency, Egyptian management, claims processing, hospitals (public and private utilization management, and alike), especially those which reporting. The “Provider” division provide services to disadvantaged would work on achieving efficient groups, should develop the ability and quality services in facilities. to cost the services they provide. • Reforming existing payers This would entail training of providing health insurance fiduciary staff; and introduction coverage to groups of households: of health monitoring information The recommendations under this systems (HMIS) to track expense heading are somewhat technical and capture physician behavior, and beyond the scope of this prescribing practices, and note in that they require in-depth ancillary costs. knowledge of the institutions involved, but essentially the (4) Improving Healthcare Quality idea is to promote universal in Public Facilities health coverage/insurance through appropriate institutional The last set of recommendations mechanisms. would improve quality of care in • Defining and costing package facilities, especially in lagging of services: In order to provide regions, through performance-based a package of essential health incentives, accreditation, training, services to disadvantage and citizens’ engagement. Five groups within budget envelopes, recommendations are made. appropriate costing is required 81 Social Sector Note • Training of providers in line of care, including in Egypt. One with new healthcare demands: aim of such incentives would be The current skill mix of Egypt’s to attract personnel in lagging medical workforce may not allow regions, including possibly through them to adequately respond to accelerated career progression, increasing healthcare demands, exposure to training facilities at thus requiring task shifting and nearby centers of excellence, and retraining. In Upper Egypt, government-guaranteed and pre- where physicians’ availability negotiated contracts for working is lowest, nursing staff could be within or outside the country after further trained to perform basic a set number of years in service. procedures to improve health Negative incentives to discourage outcomes, after appropriate professionals from working training and legal frameworks in non-lagging regions could are in place. Training providers include caps on available job on responsiveness is also key to openings, frequent staff rotations, increase patient satisfaction. Due and stipulation of service in a to inappropriate incentives, dual lagging region for a set period of practice should be regulated, and time before eligibility for payment then gradually phased out. bonuses. • Attaining independent • Increasing citizen participation accreditation for public facilities: in service delivery: This could be Egypt should start working done through a national strategy for towards at least foundation- citizens’ engagement, the creation level accreditation for public of an office for engagement providers to ensure quality and with civil society at the national as a prerequisite for eventual level and the establishment of a contracting with strategic Committee for Patient Rights at payer(s). Only facilities that meet the facility level. Information on at a minimum the Foundation performance must be linked with Accreditation Level for hospitals mechanisms that allow citizens, and the Provisional or Full service providers, and officials Accreditation Level for primary to share and act on it. Collecting centers would be eligible for feedback on public services from contracting. users, benchmarking service • Scaling up performance-based delivery and local governance financing and other incentives: performance and disseminating Structuring a payment system with information on performance can performance-based incentives for also provide a rigorous basis for providers has been shown to be citizen action. successful at improving quality • Establishing grievance redress 82 Social Sector Note mechanisms and progressive Three different programs could be legislature: This could include relied upon to achieve universal the development of a medical health coverage, with each program malpractice law, the creation of adapted to particular features of the a uniform Patient Bill of Rights geographic areas served. (PBR), and harmonization of existing laws and decrees related 1. Progressive Coverage of the to health. The PBR should Poor Regions include patients’ right to accurate (Upper Egypt UHC Initiative) and easily understandable information; choice of healthcare • Upgrading supply through provider; emergency services; prioritizing and coordinating taking part in treatment decisions; investments and recurrent budget respect and nondiscrimination; for service delivery of primary confidentiality and privacy of and secondary health care in health service and information; Upper Egypt. Also, improve and fair, fast, and objective providers’ technical skills and review. responsiveness. • Establishing a strategic purchaser V. PROGRAM OPTIONS for family health services. Merge the Program for the Poor and the In terms of specific programs Family Health Funds in Upper options, a first priority would Egypt as a single purchaser be to achieve universal health pseudo-agency. coverage. • Enrolling all citizens based on residence. With high poverty in This program aims to provide health the region, including the poor coverage for populations living in and vulnerable workers is key in different geographical zones of the Upper Egypt. In follow-up phases, country through targeted reforms poorer Governorates in Lower and financing interventions spanning Egypt could be included as well. a period of six to eight years of • Guaranteeing financing for phased approaches culminating in primary and secondary care. the envisioned universal mandatory This should include services with Social Health Insurance. Three positive externalities, public or sub-programs are identified as quasi-public goods. Those should part of this first priority area, and be funded from general and/or each subprogram includes a list of ear-marked taxation and cross- recommended actions. subsidized from pre-payments from HIO beneficiaries. • Linking coverage for tertiary care 83 Social Sector Note and catastrophic illnesses to • Establishing the legal backbone. HIO and PTES. Establishing an Legislative action will be access to HIO/PTES coverage needed for the SHI as well as for the treatment of expensive/ pertinent executive decrees and advanced services on the basis regulations. of enrollment in Upper Egypt • Building capacity for health UHC initiative will guarantee an insurance functions. Capacity efficient referral system. will be needed for introducing • Instituting capitation and health insurance functions performance payments. Gradually within the SHI including change the payment from budget beneficiary management, lines to capitations based on provider management, claims population. Incentivize additional management, utilization payments through performance/ management and medical audits, results frameworks to improve fraud detection and price setting service quality. mechanisms. • Unifying SHI rules and 2. Canal Region Social Health regulations. A positive list of Insurance Initiative health services must be defined. (The Big Bang Approach) A list of common qualified public and private providers must Endowed with the highest GDP per also be established with proper capita, largest percentages of health classification. This would also insured population, a small population require defining the provider- and the lowest poverty rates in the payment mechanism, contracting country, the Suez Canal region mechanisms and align beneficiary Governorates have been viewed as enrollment and registration tools. the most ready to start implementing • Building capacity among providers the new Social Health Insurance for contracting. A rigorous and Initiative (SHI). Yet building on structured training program on previous experiences in piloting the fiduciary management such new system in the same zone (The as costing, contracting, claims Suez pilot of 2006-2010), successful generation and auditing must be implementation in this region would instituted. In addition, providers require at least 3-4 years due to must be trained on delivering the the need for initial setting up of the contracted package of services required systems. Rolling over to as per the guidelines for diagnosis other Governorates will build on and treatment. acquired experiences and systems while facing less implementation challenges. 84 Social Sector Note 3. Social Health Insurance introducing policies to discourage Transition the practice and encouraging (Other Regions) those who opted out to re-enroll their employees. While special attention should be • Defining provider payment given to the Suez Canal Region and mechanisms within HIO. Apply Upper Egypt, the rest of the country unified provider payment equally should not be left behind in terms of between HIO providers, including reforms. This will have the double HIO’s own hospitals/clinics and benefit of increasing the readiness expand contracted services of existing institutions for takeover by with other public and private SHI and providing citizens in those providers based on competition, areas with improved and reformed accreditation and a fair price list. services while they wait for the • Upgrading purchasing functions transition (which may take a decade within PTES. The fund could in some areas). find room for efficiencies by negotiating prices with providers • Establishing a purchaser- instead of blanket-pricing all. provider split within HIO. An • Improving beneficiary targeting internal separation of functions by PTES by prioritizing access between the two different arms to disadvantaged groups and of the organization will improve gradually crowding out the accountability and efficiency. financially better off. This would • Expanding enrollment for families require enrolling the poor and of HIO enrollees. Moving towards vulnerable as well as non-poor family enrollment by expanding informal workers in PTES to contributory mechanisms to increase access to those groups enroll families of formal sector and help capture those individuals employees will increase coverage within the overall system. with lower risk pools and added • Establishing an independent contributions. accreditation organization that • Improving enrollment of other would be autonomous with beneficiaries within HIO. jurisdiction over all facilities in This could be attained with the country (public, private, etc.) communication campaigns and For providers accreditation would enrollment mechanisms/venues be required for contracting, with to enroll more female headed periodic renewal. households, under-five children, • Boosting provider’s capacity for school-age children, and farmers quality assurance by strengthening and reduce adverse selection. internal departments within MOH • Decreasing HIO opt-out by and HIO, as well as other provider 85 Social Sector Note organizations to ensure quality at etc. should be carried out. A proper central and peripheral levels. follow-up mechanism for following up on patients and handling their A specific focus should also be grievances is needed for accurate placed on the prevention, control measurement of treatment and treatment of Hepatitis C given compliance and effectiveness. especially high prevalence rates • Treating patients. Egypt should in Egypt among disadvantaged pursue its ongoing efforts to groups. further decrease drug prices while subsidizing the poor and A second priority or program the vulnerable. HIO should should be the prevention, control be cross-subsidized from the and treatment of Hepatitis C. general budget to minimize the implicit rationing of treatment for This program could have three sub- patients. priorities. As a third priority, attention should • Strengthening infection control be placed on policies and programs and blood safety. Multiple related to population and early measures should be taken in childhood. that regards including allocating sustainable resources for A third priority or program should infection control and blood focus on population and early safety; launching and scaling up childhood development. the use of disposable syringes; and establishing compliance Owing to the variety and multitude with infection control protocols of challenges, a dedicated multi- as a mandatory requirement for sectoral program is recommended. funding and/or contracting health General features of such a program facilities. could be as follows: • Ensuring early detection and • Selecting priority areas of focus/ reaching more patients. Egypt interventions. Both demand should adopt and conduct a and supply side policies should screening program for hepatitis be considered with proper C. Citizens should be sensitized engagement of both the public to conduct voluntary testing and and civil society sectors. A counseling. Mass communication separate note in this series listed outreach campaigns to inform in references considers early citizens about modes of childhood development programs transmission, mechanism for in more details registration, treatment options, • Establishing a multi-sectoral 86 Social Sector Note financing facility. Such a facility The analysis suggests that Egypt should be publicly financed, faces major challenges, and in many but with possibly with additional areas may not be performing as well contributions from civil society. as one might expect given the level of It should support interventions economic development of the country. that work across sectors, Of special concern are poor health including health, education, outcomes for disadvantaged groups. social protection, and across In terms of options to deal with existing organizations of different challenges, the note relied in part on nature. The facility would also recommendations made in a World support planning, monitoring, Bank (2015) study. To ensure the and evaluating programs and progressive realization of universal verifying results while actual health coverage and improve implementation would take place outcomes for disadvantaged groups, at decentralized levels. priorities could include expanding the provision of a package of family health services especially in lagging III. CONCLUSION areas and increasing insurance coverage for disadvantaged groups This note was prepared as part of in order to reduce out of pocket a technical assistance task on the payments. A range of incentives and social sectors. It had two objectives. trainings for improving the quality The first was to provide a rapid of care in public facilities could also diagnostic of selected features of be provided. Finally, in some areas the health sector, including in terms Egypt is facing challenges peculiar of benchmarking health indicators to the country. As one example of internationally and analyzing health such challenges, the note included spending, both by the government and a discussion of FGC, together with by households. Specific challenges some insights from programs that such those related to ECD, Hepatitis have shown promise to curtail the C and FGC were also discussed. practice in other countries. The second objective was to explore policy options and interventions that could be implemented to improve health outcomes, including in the areas of service delivery, financial protection, and quality of care, with the aim to achieve social justice in health. 87 Social Sector Note References Nutrition and Population Sector Strategy for MENA (2013-2018), Denboba, A., R. Sayre, Q. Wodon, Washington, DC: The World Bank. L. Elder, L. Rawlings, and J. Lombardi, 2014, Stepping up Early World Bank, 2015, A Roadmap to Childhood Development: Investing Achieve Social Justice in Healthcare in Young Children with High Returns, in Egypt, Washington DC: The World Washington, DC: The World Bank. Bank. Hamed, A., 2016, Going Universal: Strategic Directions for Egypt>s Health Sector, mimeo, Cairo: World Bank. Rashad, A. S. and M. F. Sharaf, 2015, Catastrophic and Impoverishing Effects of Out-of-Pocket Health Expenditure: New Evidence from Egypt, American Journal of Economics 5(5): 526-533 Wodon, Q., E. Calimoutou, C. Male, M. C. Nguyen, A. Onagoruwa, A. Savadogo, and A. Yedan, 2016b, Ending Child Marriage for Egypt’s Development, Egypt Social Sector This note was prepared by a World Bank team Note, Washington, DC: The World as an input into a technical assistance task for Bank. Egypt’s Ministry of Finance. Comments from Caroline Krafft, Nistha Sinha, and participants at a review meeting for the note are gratefully Wodon, Q., B. Evans, A. Kazem, C. acknowledged. Support from Gustavo Demarco Male, A. Onagoruwa, S. Paksima, for the preparation of this note is also gratefully A. Savadogo, and A. Yedan, 2016b, acknowledged. Guidance was provided by Asad Selected Issues and Options in Alam. The note benefitted from partial funding from the Global Partnership for Education (for the the Education Sector, Egypt Social relationships between education, child marriage, Sector Note, Washington, DC: The and health outcomes) as part of a global research World Bank. task on out of school children and disadvantaged groups. The opinions expressed in the notes and World Bank, 2013, Fairness and related studies are those of the authors only and Accountability: Engaging in Health need not represent the views of the World Bank, its Executive Directors, or the countries they Systems in the Middle East and represent. North Africa - The World Bank Health 88 Social Sector Note KEY MESSAGES: • Child marriage and early childbirth have large negative impacts and economic costs for the girls marrying early, their children, their communities, and society. Impacts and costs are observed for education, health, nutrition, fertility, work, and earnings among others. • This note first provides a diagnostic of issues related to child marriage and early childbirth. Next, the note discusses policies and programs that could help eliminate child marriage. INTRODUCTION participation and earnings for girls in adulthood, and finally (5) various This note, the third in a series on forms of agency as well as well- the social sectors (see Box 1), has being. two objectives. The first objective is to provide a rapid diagnostic of key The second objective of the note is issues related to child marriage. to outline the type of programs and The note first discusses the trends policies that could be implemented in child marriage and in early to end child marriage. This is done childbirth, noting that in Egypt most first through a rapid review of the early childbirths are related to child literature, next through an analysis marriage. Next, the note discusses of the steps already taken by the the negative impact of child marriage government in this area, and finally on development outcomes in five through a typology of needs and areas: (1) education attainment for options for programs depending girls; (2) fertility, (3) child health as on the needs of specific groups of measured by under-five mortality vulnerable girls. and malnutrition; (4) labor market 89 Social Sector Note Box 1: Series Primer Child marriage affects more than 40,000 girls each day worldwide, Why a series of notes on the social especially in sub-Saharan Africa sectors in Egypt? The Ministry of and South Asia where almost half Finance of Egypt is aiming to improve of girls continue to marry before the outcomes in the social sectors and age of 18. The practice leads women increase the benefits of public spending to have children earlier and more for the population in order to contribute to poverty reduction and development. children over their lifetime than if they This note is part of a series discussing had married later. It also affects girl’s selected issues in the social sectors, education attainment and literacy especially in health and education. negatively, thereby curtailing future opportunities for them to compete What are the topics discussed in the for well-paying jobs and reducing series? The series focuses on education economic growth. Child marriage and health, but considers labor market as also leads to early childbirth (having well since these outcomes are affected a child before the age of 18), higher by outcomes in education and health. health risks for young mothers and Special topics are also considered, their children. Finally, child marriage including early childhood development reduces voice and agency for women and child marriage. The analysis is based in large part on recent household and it may increase intimate partner survey data. violence. What is the question asked in this The international community is synthesis note? The question is: how aware of the negative impacts of important is the issue of child marriage in child marriage on a wide range Egypt and what could be done to prevent of development outcomes. This the practice? awareness has led child marriage to be prohibited by law in many countries. How is the question answered? The But legislation is not enough. note first provides a rapid diagnostic Targeted interventions are needed to of issues related to child marriage and end the practice, not only to deal with early childbirth. The note considers next commitments made by the government economic constraints contributing and options from the literature for ending to child marriage, but also to tackle child marriage. social norms as well as cultural and in some cases religious traditions I. IMPORTANCE OF CHILD that contribute to the persistence of MARRIAGE the practice. Ending child marriage is part of the Sustainable Development Globally, child marriage has been Goals, but actual investments to end recognized as a major issue in the the practice remain limited. This is Sustainable Development Goals. in part because the large economic 90 Social Sector Note costs of the practice have not yet II. RAPID DIAGNOSTIC – been demonstrated, so that the SELECTED ISSUES priority to be given to this issue has not yet been acknowledged. (1) Trend in Child Marriage and Early Childbirth Egypt is part of a handful of countries whose governments have recently The incidences of child marriage adopted national strategies for the and early childbirth remain high prevention of child marriage (in 2014 even though both practices have in Egypt). been decreasing substantially over the last two decades. In Egypt, the Government has recently made important Child marriage has decreased in the commitments towards ending developing world, but only very slowly. the practice of child marriage, In the past 30 years, the incidence including through the adoption of of child marriage decreased by only a strategy. 11 percentage points across a set of 60 countries (Nguyen and Wodon, As will be discussed in more 2015). details in this note, Egypt is party to key international and regional In Egypt, as shown in table 1, the conventions that protect children share of women aged 18-22 who and women against discrimination married before the age of 18 was and guarantee their rights, including 16.5 percent according to the latest the right nor to be forced to marry Demographic and Health Survey early. In addition, the minimum legal implemented in 2014. This incidence age of marriage in Egypt was set in has decreased substantially over 2008 at 18 for both men and women time, but nevertheless remains high. (Law no. 126), even if enforcement In addition, only one ten women aged remains weak. Most importantly, 18-22 have had their first child before the government adopted in 2014 a the age of 18, even if there has also strategy against child marriage, with been a large decline over time in the aim to reduce the prevalence of early childbirth (having a first child child marriage by 50 percent within before the age of 18). a five year time-frame, which is ambitious. The challenge now relies The share of women aged 18-22 who on implementing the strategy through married before the age of 18 was adequately designed and funded 16.5 percent according to the latest policies and programs. DHS. This incidence has decreased over time. One in ten women ages 18-22 have their first child before 18. 91 Social Sector Note Table 1: Trend in the Incidence of Child Figure 1: Child Marriage (%) and GNI Marriage and Early Childbirth (%) per capita (US$) Source: Compiled by the authors using World Bank and UNFPA data. Source: Authors’ estimation with 2014 EDHS. In some countries, a substantial share As shown in Figure 1, richer of early childbirths may take place countries have lower levels of child before or outside of marriage. But in marriage than poorer countries. But most countries, this is not the case. In there is also a lot of variation around Egypt, there is a strong relationship the central tendency, pointing to the between the age of the mother at first importance of other factors in leading birth and the age at first marriage as to the practice. Ideally, child marriage communities do not look favorably at should be banned by law. But this may births out of wedlock. not be enough. Many countries with a high incidence of child marriage have Data from the DHS cover only married laws banning the practice. women in Egypt, but among those, early childbirth is almost always This suggests that enforcement as taking place after marriage, as shown well as targeted programs matter in table 2 where the shares of girls as much as the law. In the specific with an early childbirth is provided case of Egypt, the incidence of according to three categories in terms child marriage is slightly above of the timing of marriage among expectations given the country’s level married women ages 18-22. Given of economic development (Egypt that most early childbirths take place is represented in the Figure by the after marriage, hence delaying the red dot). This highlights the need for age at marriage is essential to avoid stronger policies and programs to early childbirth. end child marriage. 92 Social Sector Note Table 2: Marriage and Early Childbirth, Age 1822- (%) Child marriage and early pregnancies (Sample of Married Women) have negative effects on a wide range of other outcomes. This is illustrated visually in Figure 2 which outlines impact according Source: Authors’ estimation with 2014 EDHS. to five broad domains: (1) fertility Sample of married women. and population growth; (2) health, nutrition and violence; (3) education (2) Framework to Assess the attainment and learning; (4) Economic and Social Cost of participation in the labor force and Child Marriage earnings; and (5) decision-making and agency for women. Negative Child marriage has negative effects impacts are observed not only for the on a wide range of outcomes. girls marrying early, but also for their Estimating these impacts helps children, for their communities, and make the case for investments for society as a whole. towards ending the practice. Figure 2: Framework for Analyzing the Impacts and Costs of Child Marriage Source: Wodon et al. (2015). 93 Social Sector Note Measuring the negative impacts of The age group is chosen in order to child marriage helps in making the make sure that girls who may have case for investments and interventions completed secondary school at a towards ending the practice. The later age than the standard age for first part of this note provides results completion are accounted for. from such estimations. In the second part, more information is provided Table 3 provides the share of women on the context of child marriage in who enrolled at the secondary Egypt with a discussion of some school level as well as the share of the interventions that could be who completed secondary schooling considered to end the practice. according to whether they married as children or not. There are large Child marriage has negative effects on statistical differences in enrollment a wide range of outcomes, including and completion rates by child (1) fertility and population growth; marriage status. While 78.7 percent (2) health, nutrition and violence; (3) of married women aged 25 to 34 who education attainment and learning; did not marry as children enrolled in (4) participation in the labor force and secondary school, the proportion is earnings; and (5) decision-making 49.6 percent for those who married and agency for women. as children. Large differences are also observed for secondary school (3) Impact of Child Marriage on completion. When girls marry below Education the age of 18, the probability that they will complete secondary school is Women marrying early are less much lower. The differences in mean likely to complete secondary school enrollment and completion school than if they marry later. rates between the two groups are Controlling for other factors, statistically significant. child marriage reduces secondary school enrollment and completion The probability of completing substantially. secondary education for women ages 25-34 who married after 18 is The analysis is again based on data 38.1 points higher than for women from the latest Demographic and who married as children. Health Survey for Egypt implemented in 2014. Basic statistics on education Table 3: Child Marriage and Secondary Education attainment for women who married as children and those who married later are provided in table 3. The sample is that of women between the ages of 25 and 34 who have married. Source: Nguyen and Wodon (2016). 94 Social Sector Note Estimating the actual impact of child in box 2, it also underscores the marriage on education attainment importance of schooling as a way to is not straightforward because the delay marriage. decisions by a girl (or her parents) to marry early and drop out of school Box 2: Continued Schooling as a may be taken together. Education Strategy to Delay Marriage attainment depends on whether a The causality between early marriage girl marries, but the decision to marry and education goes both ways. Early may also depend on (in technical marriage reduces a girl’s education terms be endogenous to) a girl’s prospects, but a lack of education education prospects. For many girls opportunities or education of low quality the path is either to continue to go to together with limited employment school or to marry, but not both. This prospects for better educated girls are implies that the causality between factors that lead to early marriage too. marriage and schooling may run both This is why apart from recommending an ways. international summit on early marriage (which took place in 2014 in London) and the adoption of national strategies for For example, the decision to drop eliminating early marriage, Brown (2012) out may be a function of a girl’s suggested looking at “tipping-point” education potential, or the lack of policies in education, including programs opportunities provided by a better to reduce the cost for girls to transition education where she lives, and not from primary to secondary school, to directly a consequence of marriage. help eliminate child marriage. In that case, because the decisions to marry and drop out may be observed In order to measure the impact of child simultaneously, causality could be marriage at the margin on secondary wrongly inferred from child marriage school enrollment and completion, to dropping out. The impact of child regression analysis with instrumental marriage on education could be variables is needed. Details of the overestimated, especially in contexts methodology as provided in Nguyen where norms around appropriate and Wodon (2016). Key results are ages for marriage are flexible, so that provided in table 4. The interpretation parents and girls have discretion to of the coefficients is in percentage delay marriage should girls be adept terms. at schooling. The factors leading to the decisions to marry and drop out Marrying as a child has a large and of school are complex and inter- statistically significant negative effect related. This makes it more difficult to on secondary school enrollment and estimate the impact of child marriage completion as compared to marrying on education than is the case for after the age of 18. some other outcomes. But as noted 95 Social Sector Note The estimation procedure provides the girl had not married. Because of so-called average partial effects of the risk of omitted variable bias, part marrying before 18 by year of early of the effect associated with child marriage. This means that marginal marriage could actually measure effects are available for different age other factors that lead to dropping at marriage. For example, in the case out. of secondary school completion, a girl who marries at 16 has a 16.9 Table 4: Estimated Impact of the Age at percentage point lower probability of Marriage on Girls’ Education Attainment, completion than if she had married Average Partial Effects after 18. The earlier a girl marries, the larger the negative impact of child marriage is on education attainment. The magnitude of the effects is large, and higher than the effects obtained for example for sub-Saharan Africa Source: Nguyen and Wodon (2016). as a whole by Nguyen and Wodon Levels of statistical significance: *** 1%, ** 5%, (2015a). These estimates may be * 10%. on the high side. Still, there does seem to be a negative impact of child Box 3: Risk of Omitted Variable Bias marriage on education attainment for girls, even if caution is needed for Child marriage appears to be negatively interpretation due to the risk of omitted correlated with secondary school variable bias, a somewhat separate enrollment and completion after issue from that of endogeneity controlling for other factors that may also discussed earlier (see Box 3). For affect education attainment. This could example, a girl who marries at 13 indicate a causal effect of child marriage on schooling. However, other variables and drops out of school could well be correlated with both child marriage and from a family that doesn’t believe in schooling not included in the analysis educating girls beyond the primary could be at the source of the correlation level. In that case, she might have observed between child marriage and dropped out of school at that age schooling. This issue is different from anyway, whether married or not. In the separate concern with endogeneity the absence of good variables in the discussed in the methodological annex. data to capture properly the parent’s Even if the issue of endogeneity could preferences, the effect could be be dealt with satisfactorily, because of associated with child marriage in the the risk of omitted variable, the results regression estimates, but they would cannot be considered as fully conclusive in that case relate to deeper and regarding a causal impact of child marriage on schooling, and there could unobserved preferences in the family be bias in the estimated effects. that would have played out even if 96 Social Sector Note The fact that child marriage contributes Table 5: Reasons for Dropping out for to lower education attainment among Girls, 2012 girls also emerges from responses by parents as to why their daughter has dropped out of school, especially at the secondary and TVET level. The fact that child marriage contributes to lower education attainment among girls also emerges from responses by parents as to why girls drop out of school at the preparatory and secondary/TVET level. Table 5, based on a more detailed analysis available in a separate note in this Source: Authors’ estimation using 2012 ELMPS. series, provides statistics on the Note: Values rounding to 0.0 not shown. reason for dropping out for girls. At the preparatory level, the main reason to In comparison to other countries with drop out is the fact that girls are not similar levels of development, the interested in pursuing their education fertility rate in Egypt are high. Child (the same finding emerges for boys). marriage contributes to this high This may denote a lack of quality fertility rate. or a mode of instruction that is not sufficiently engaging for students. In (4) Impact of Child Marriage on preparatory, one in 10 girls dropping Fertility out does so due to marriage. But at the secondary/TVET level, marriage Child marriage leads to increases is the main reason for girls to drop in fertility – the number of children out, accounting for more than one women have over their lifetime. in four (28.1 percent) girls dropping out. In addition, the fact that parents According to the latest DHS each are not willing to let girls pursue their woman gives birth on average to education is also a factor, and it can 3.5 children. Although prior to 2008, be shown that this affects girls much there had been a 25-year pattern of more than boys. This suggests a bias declining fertility in Egypt, the total on the part of parents to invest more fertility rate has recently increased, in the education of boys than girls. from an estimate of 3.0 births in the 2008 survey to 3.5 births per woman in the 2014 EDHS. This is a high fertility rate in comparison to other countries at similar levels of development. This 97 Social Sector Note is shown in Figure 3 which displays As shown in table 6, women ages the fertility rate as a function of the 3549- who married after 18 have on logarithm of GDP per capita in US$ average 3.29 births by that age. For (in purchasing power parity terms). women who married before 18, the Egypt is represented by the red dot, average is 4.61 births. The difference with a fertility above the expected (1.31 births) is statistically significant. value given the country’s economic Except for girls marrying at 12 or development. earlier (these are extreme cases that may have specific circumstances), Figure 3: Fertility and GDP per Capita the number increases when girls marry earlier, as expected. Women ages 35 -49 who married after 18 have on average 3.29 live births by that age. For women who married before 18, the average is higher at 4.61 births. Table 6: Mean Number of Children Ever Source: Compiled by the authors using World Born by Age of First Marriage, 2014 Bank data. EDHS Girls marrying early tend to have children earlier than girls who marry later. They also have more children over their lifetime. Given the importance of population growth, assessing the impact of child marriage Source: Authors’ estimation using 2015 EDHS. on fertility matters. The focus for the Standard error in parentheses. analysis is on the number of births that women have over their lifetime. To measure the impact of child For sample size reasons, we focus on marriage at the margin on the women between 35 and 49 years of number of births, regression analysis age. Some women continue to have is needed. Table 7 shows the results children after age 35, so that the total for the variables of interest with two number of births considered here models: a baseline specification and may be slightly underestimated, but the specification with the largest this should not affect too much the number of added variables as estimate of the difference in the total controls. The interpretation of the number of births for women marrying coefficients is in terms of incident rate as children (before age 18) or not. ratios. A coefficient of 1.15 for girls 98 Social Sector Note marrying at the age of 17 suggests Table 7: Impact of Child Marriage on that if a girl marries at that age, the Number of Children Ever Born by Age number of children she will have over of Marriage, 2014 EDHS her lifetime will be 15 percent higher than the number of children she would have had if she had married at age 18 or later. Controlling for socio-economic, Source: Authors’ estimation using 2014 EDHS. location, and other characteristics, Levels of statistical significance: *** 1%, ** 5%, women who marry as children have * 10%. on average 17-36 percent more children over their lifetime than The last step in the analysis consists women marrying after the age of 18. in assessing the impact of eliminating child marriage on the total fertility With the baseline specification, table rate. Results in table 8 are obtained 7 suggests that marrying at age by predicting the number of births 17 increases the number of births that women who married as children by 17.1 percent in comparison to would have had if they had married marrying at age 18 or later. Marrying later. The first column in the table earlier has a similar impact. Overall, provides the estimates of the number the impacts vary from 36.6 percent of births in the sample. The second for girls marrying at age 13 to 17.1 column provides the predicted values percent for girls marrying at age under the baseline model (results are 17. The marginal effects of early similar with other models). The third marriage do not change much when column provide the simulated number additional controls are added to the of births without child marriage. Note regressions. There is thus some that for all women who marry after the evidence that after controlling for a age of 18, there are no differences wide range of other variables, child between the predicted and simulated marriage may contribute to higher number of births marriage since fertility, but prudence remains needed these women did not marry early. when interpreting these results given the risk of omitted variable bias (as Eliminating child marriage could discussed previously in the case of reduce the country’s total fertility rate education in box 3). by 0.25 births or about seven percent. This would help reduce population growth substantially. With both the baseline and extended models, women who married early 99 Social Sector Note have on average 0.87 more children Early childbirth results in large part than if they had married later. The top from child marriage and is associated row in table 8 provides the difference with health risks for children, including that child marriage makes for the under-five mortality. According to the average number of births nationally 2014 DHS the under-five mortality (this is similar to the total fertility rate was 27 ‰. As shown in table rate), thereby factoring the share of 9, 4.29 percent of children born women who marry early at different of mothers younger than 18 die ages. The average number of births before reaching five years of age. that women have over their lifetime The proportion, which we refer to as is reduced for the country as a whole under-five mortality, is 2.33 percent by about 0.25 births without child for children born of mothers 18 to marriage or about seven percent. 34 years of age. The difference in This in turn would have a substantial under-five mortality between the two effect on demographic growth in the age groups is statistically significant. country. For children of mothers ages 35 and above under-five mortality is at 2.57 Table 8: Impact of Ending Child Marriage percent. on Fertility under the Baseline Model for the Estimations Table 9: Under-five Mortality by Age of the Mother Source: Authors’ estimations using 2014 EDHS. Source: Authors’ estimation using 2014 EDHS. In comparison to other countries with similar levels of development, the To check whether controlling for other under-five mortality rate in Egypt is factors early childbirth is associated high. Child marriage also contributes at the margin with higher under-five to this high rate. mortality, regression analysis is again used. Table 10 provides key results (5) Impact of Child Marriage with baseline and extended models. on Under-five Mortality and The interpretation of the coefficients Malnutrition is again in terms of marginal impacts in percentage terms. While early Child marriage also leads to higher childbirth may not contribute directly risks of death and malnutrition to under-five mortality in a statistically among children born of young significant way, the coefficient is mothers. nevertheless positive and it is likely that child marriage contributes 100 Social Sector Note indirectly to higher risks for children affecting stunting with baseline and through its impact among others extended models. The interpretation on birth spacing and the mother’s of the coefficients remains in terms of education, both of which do affect in marginal impacts in percentage terms. a statistically significant way the risk Under the baseline specification, for a child of dying before age five. deliveries at a young age increase the likelihood of stunting for the Table 10: Impact of Early Childbirth on children by 7.5 percentage points in Under-five Mortality foe Children Born comparison to a delivery at 18 to 34 of Young Mothers years of age (coefficient statistically significant). The difference in risk of stunting between mothers ages 1834- and mothers above 35 is not Source: Authors’ estimation using 2014 EDHS. statistically significant. Marginal Levels of statistical significance: *** 1%, ** 5%, effects do not change much when * 10%. additional controls are added (extended model). There is thus some In the case of malnutrition, with evidence that after controlling for a stunting as the indicator, the analysis wide range of other variables, early does suggest a direct impact of early childbirth may contribute to stunting, childbirth on the risk of stunting. but prudence remains needed when Considering first basic statistics in interpreting these results given the table 11. Estimates suggest that 31.69 risk of omitted variable bias (see box percent of children born of mothers 3). younger than 18 are stunted. The proportion is still high, but ten points Deliveries at a young age may lower at 21.30 percent for children increase the likelihood of stunting for born of mothers 18 to 34 years of the children by 7.5 percentage points age. The difference in stunting rate in comparison to a delivery at 18 to between these two age groups is 34 years of age. statistically significant. Table 12: Impact of Early Childbirth on Table 11: Incidence of Stunting by Age Stunting of the Mother Source: Authors’ estimation using 2014 EDHS. Source: Authors’ estimation using 2014 EDHS. Levels of statistical significance: *** 1%, ** 5%, Table 12 provides key results from * 10%. a regression analysis of the factors 101 Social Sector Note (6) Impact of Child Marriage on Estimates of the wage regressions Labor Force Participation and are available in a separate note on Earnings education in this series. The second step in the analysis consists in using Child marriage also has a negative the results of the wage regressions to impact on labor force participation assess the potential loses in earnings and earnings once the girls who for women who marry early, and for married early reach adulthood. all wage earners. The analysis for the impact of child The results of those simulations marriage on women’s labor force are provide in table 13. For women participation and earnings is based assumed to have married early, on data from Egypt’s 2012 labor earnings would be eight percent force survey. higher if they had married later. When • First, wage regressions are considering all women, including estimated to assess the impact those who did not marry early, this of the number of children in the translates into an impact on earnings household and the education of 0.96 percent (only one in seven level of women on the likelihood women marries early, and in addition of labor force participation with they tend to have lower wages than positive earnings and expected those who marry later). Finally, when earnings. This matters because considering earnings for both men by affecting fertility and education and women, ending child marriage attainment, child marriage has could increase earnings for all indirect effects on labor force workers with pay by 0.38 percent. participation and earnings. In addition, an advantage of Eliminating child marriage could Egypt’s labor force survey is that increase earnings for women it does ask about the age at first marrying early by eight percentage marriage, so the direct impact points, yielding wage gains for the of child marriage on work and overall population of 0.38 point. earnings can also be assessed. This could be valued at $2.9 billion • In the second step of the analysis, per year in purchasing power parity the impact of child marriage on terms. work and earnings – including both direct and indirect impacts – Table 13: Impact of Child Marriage on is estimated for the women who Earnings married early as well as for the overall sample of workers with positive earnings. Source: Authors’ estimation using 2012 ELMPS. 102 Social Sector Note What would be the monetary value indirect effects of child marriage are of those gains? Assume for simplicity not factored in the analysis, and none that the impact simulated with of the multiplier effects from higher earnings is valid for other types of earnings in the economy are taken work done by women. This would into account, so the effect could also mean, for example, that household be larger. Overall, this estimate at production on family land might also least gives a rough idea of the order increase by amounts similar to those of magnitude of the cost of child provided in table 15. More generally, marriage in monetary terms through the assumption is that all sources of reduced labor force participation and household income and production earnings, as one example of the might increase by those amount. monetary costs associated with child Assume next that in the long run marriage. household consumption is similar to household income (limited ability of many households to save). These (7) Child Marriage and Well-being are rather strong assumptions, but they help give an order of magnitude A recent survey suggests that child for potential monetary gains. marriage is wished for by only a small share of young women, but According to World Bank data, gross parents have a substantial say national Income in Egypt was US$ when girls marry early, possibly 919.2 billion in purchasing power leading to lower levels of well- parity (PPP) terms in 2014 and US$ being. 286.5 billion in current (market rate) US$ value, generating a PPP to Table 14 provides summary statistics current value ratio of 3.2. Household regarding perceptions about marriage consumption expenditure was US$ from the 2014 Survey of Young 237.3 billion in current value or US$ People in Egypt implemented by the 761.3 billion in PPP terms. If the gain Population Council. The comparison in consumption from the elimination made is between married women of child marriage is at 0.38 percent who married before the age of 18, of the existing level of consumption and those who married later. (as per the assumptions above), the benefit from eliminating child marriage Table 14: Perceptions Regarding would be valued at about US$ 2.9 Marriage, 2014 billion in PPP terms (0.63 percent of US$ 761.3 billion) or US$ 902 million in current US$ value. This could be overestimated for several reasons, but at the same time other potential 103 Social Sector Note husbands related to them. • The final decision on whom to marry was more often made by parents in the case of child marriage than when women married later, and women who married as children were also more likely to live with the spouse’s family. • A smaller share of women who married as children declared being happy, while a larger number declared that happiness in their marriage did not matter as long as they were able to care for their children. Only a small minority of young women believe that girls should marry before the age of 18. Marriage is more often decided by parents when a girl marries early resulting in a higher share of girls marrying a relative and living with the spouse’s parents. There are also indications that a smaller share of women who married as children are happy in marriage or think that such happiness matters. III. LESSONS FROM THE Source: Authors’ estimation using 2014 SYPE. LITERATURE ON POLICIES TO END CHILD MARRIAGE A number of results stand out: • Only a small minority of young According to the literature, several women believe that girls should types of policies and programs be married before the age of must be combined in order 18. This is also the case for to prevent child marriage and the women who did marry as improving development outcomes children. The data also suggest for adolescent girls at risk of that a larger proportion of women marrying early. marrying early were married to 104 Social Sector Note The analysis in the previous section girls with information, skills and suggests that the economic costs support networks. The idea is of child marriage in Egypt are likely to help girls know themselves, to be large, and that the practice their context, and their options remains accepted, at least among by providing them with valuable parts of the population. This suggests information and training in a “safe that decisive interventions should be space” environment while also implemented to end the practice. reducing their isolation. Many of Past research provides guidance on the interventions mentioned in the types of actions that could help table 15 could be considered for end the practice. Egypt, including life skills training, vocational and livelihoods skills A useful starting point is the review training, mentored learning of 23 programs with some evaluation spaces to facilitate the acquisition of impact conducted by Malhotra of core academic skills, and safe et al. (2011). The authors identify spaces that allow girls to connect five strategies to prevent or delay and socialize outside the home. early marriage (see table 15): (1) Empowering girls with information, • Engaging parents and skills, and support networks; (2) communities. Programs aiming Educating and mobilizing parents to empower girls are typically and community members; (3) implemented together with Enhancing the accessibility and efforts to engage parents and quality of formal schooling for girls; communities so that an “enabling (4) Offering economic support and environment” is created and incentives for girls and their families; the stigma associated with and (5) Fostering an enabling legal delaying marriage is reduced. and policy framework. The interventions in this group aim to change social norms and Multiple strategies can help prevent reduce the pressure to marry child marriage. These strategies range early. Engaging parents and (among others) from empowering communities is also important to girls with information, skills, and mitigate any potential unintended support networks to enhancing negative consequences of girls’ opportunities for continued schooling participation in the programs. A for girls and adopting an appropriate number of programs have found legal framework. that such activities are useful when introducing a new program • Empowering girls. Most of the for girls. At the same time interventions reviewed by Malhotra however, such type of community et al. (2013) aimed to empower engagement alone rarely has 105 Social Sector Note impact. Rather it is the concrete enabling environment to eliminate and tangible benefits of the girls the practice. In Egypt such laws programming that facilitates already exist, but they may not change. necessarily have the desired effect if not accompanied by mechanisms • Improving the quality of formal to enforce or accompany laws schooling and education with appropriate complementary opportunities for girls. This is a interventions, as discussed below. challenge in Egypt where too This means that multi-strategy many girls drop out of secondary approaches that combine laws school in part because of concerns with raising awareness among about quality. Unless schools national decision-makers and improve, become affordable, and local leaders of the importance provide credible alternatives to to eliminate early marriage and early marriage for the girls most targeted interventions are more at risk, hoping that schooling will likely to be successful. work as a mechanism to reduce early marriage may not work as Table 15: Strategies to Prevent Early well as expected. Marriage • Providing incentives and economic support. The issue of the opportunity costs and out- of-pocket costs associated with schooling are major issues for girls not to pursue their education. Education in public schools is in principle free, but costs remain for households. Various incentives such as conditional cash transfers could help in making sure that girls do pursue their secondary education. Economic support through microfinance and other programs fostering employment also holds promise. • Enacting laws and policies. Finally, in some countries enacting laws to prevent marriage before the age of 18 should be part of the Source: Adapted from Malhotra et al. (2011). 106 Social Sector Note Examples of programs related to responsibility for state parties each of these five areas of focus are to take appropriate steps to provided in table 18 (a few programs ensure equality of rights and included in the table have been added responsibilities of spouses at the on top of the programs identified by time marriage, when married, and the authors). Not all interventions during its dissolution; are necessarily applicable or should be considered as priorities in the • The International Convention case of Egypt, but the list is a good on the Elimination of All Forms start to consider options based on of Racial Discrimination against international experience. Women (CEDAW) (Articles 2 and 16 (1b;2) relates to discrimination against women in all its forms IV. GOVERNMENT PRIORITIES and the need to take appropriate measures to eliminate In terms of the legal framework, discrimination in matters related Egypt has ratified or acceded to marriage and family relations; most international and regional conventions that have relevance • The Convention on the Rights for child and forced marriage. of the Child (Articles 1,12 ,3- 36-34 ,29-28 ,24.3 ,19) relates As shown in Table 16, Egypt is party to children’s protection from to key international and regional discrimination. Supplementary conventions that protect children and Convention on the Abolition of women against discrimination and Slavery, the Slave Trade, and guarantee their rights, including the Institutions and Practices Similar right nor to be forced to marry early: to Slavery calls for parties to commit to abolish and abandon • The International Covenant on debt bondage, serfdom, servile Economic, Social and Cultural marriage and child servitude Rights (Article 10) relates to (Article 1) and enacting minimum protection against economic and ages of marriage, encouraging social exploitation; registration of marriages, and encouraging the public declaration • The International Covenant on of consent to marriage (Article civil and Political Rights (Article 2). 23) relates to the right for men and women of marriageable age • The African Charter on the Rights to marry and to found a family and Welfare of the Child identifies with protection of the free and early marriage as a harmful social full consent to marry and with practice, and calls for states to 107 Social Sector Note prohibit the practice by taking prohibiting and criminalizing sex legislation and making registration trafficking, compulsory exploitation, of all marriages mandatory in an and forced labor. official registry (Article 21). The Civil Status Act amended in Table 16: Ratification by Egypt of Key 2008 sets the minimum legal age Conventions of marriage at 18 for both men and women. However, enforcement of the minimum age is weak. Table 17: Legislation Pertaining to Child marriage Source: Compiled by the Authors. In addition, the minimum legal age of marriage in Egypt was set in 2008 at 18 for both men and women. Unfortunately enforcement remains relatively weak. In 2008 the People’s Assembly approved Law no 126 (2008) which amended several legislations including those for the minimum age Source: Compiled by the authors. at marriage. Table 17 lists some of the provisions. There was intense Still, despite major legislative debate regarding the minimum age achievements pertaining to at marriage, and attempts have been the minimum age for marriage, made since to lower it (including enforcement is weak according to the legislation proposed but defeated WHO-UNODC-UNDP report Global in 2012 that would have permitted Status Report on Violence Prevention girls to marry at nine years old). for 2014. The report classifies countries The new Constitution adopted in as having limited or weak enforcement 2014 strengthened legal protection if laws are enforced to a limited extent for children including by explicitly and less that 40 percent effective. 108 Social Sector Note Countries get an intermediate rating Egypt is part of a handful of countries if laws are enforced to a large extent whose government has recently (40 percent to 79 percent effective). adopted a national strategy for the Countries get the highest rating if prevention of child marriage (in laws are fully enforced (80 percent 2014). International experience or more effective). Egypt is rated as provides insights into programs and having weak enforcement of the legal policies that could make a difference age of marriage. to end the practice. Girls marrying early are less likely to The government adopted in 2014 know about mandatory pre-marriage a strategy against child marriage. examinations, and are also less likely International experience provides to have undergone the evaluation, insights into programs that could which may put them at risk among make a difference. others of transmittable diseases. The government took a major step Despite an appropriate legal towards ending child marriage framework, the practice of child through the adoption of a national marriage remains prevalent however, strategy in 2014 for the prevention of and data suggest that some of the the practice. As part of the broader provisions in recently adopted laws national population and development may not be followed yet, with higher agenda, the strategy aims to reduce risk for girls marrying early. For the prevalence of early marriage by example, as shown in table 18, data 50 percent within a five year time- from the 2014 SYPE survey suggest frame, which is ambitious. It focuses that girls marrying early are less efforts on areas within Egypt with likely to know about the mandatory the highest rates and in some cases pre-marriage examination, and are increasing rates of child marriage. also less likely to have undergone The strategy has five operational the evaluation, which may put them directions: empowering girls at risk among others of transmittable (including economic empowerment); diseases. supporting girls who were married early to minimize the negative Table 18: Pre-marriage Examinations impacts on them, their children and families; completing and updating legislation to ensure that exiting protections are working in favor of girls and women; empowering, educating and preparing young girls so they can tackle family and societal Source: Authors’ estimation using 2014 SYPE. pressures; and finally working with 109 Social Sector Note families and communities to ensure girls. In addition, low quality of that they understand the harmful education in many schools does consequences of child marriage. not encourage parents to invest in their daughters’ education. In order to improve school quality, a focus on basic skills acquisition should be V. TYPOLOGY OF PROGRAM a priority for girls ages 13-16 apart OPTIONS BY VULNERABLE from the provision of well targeted GROUPS transfers or other programs to help offset the cost of schooling. Finally, Experience from other countries can girls in that group also need life shed light on the types of programs skills training. Similarly, for girls in that could help delay early marriage, school ages 17-18, schooling must as well as support the needs of girls provide value. This can be achieved still marrying early. by focusing more on preparing girls for formal labor market positions One of the basic ideas is to target and careers in which the girls can specific programs to the needs of in adulthood serve as models for various groups of adolescent girls. younger girls. An illustration of this approach is provided in table 19 inspired and Interventions and policies should adapted from a typology prepared be adapted to the needs of the for Niger. While the reality of the life adolescent girls being served. These in the Sahel is very different from that needs are not the same depending in Egypt, some of the interventions on the age of the girls. They also would still apply, but would need to differ depending on whether the girls be adapted to country context (for an are still in school or not, and whether example of a successful program in they are already married or not. Egypt, see Box 4). For girls out of school, interventions In the typology provided in table 19, differ depending on whether they the first two groups of girls are still are married or not. For girls not in school. Most parents in many yet married, the key may again countries regard formal education be to provide a viable alternative as an acceptable alternative to to marriage. Programs could early marriage. But the cost of focus on building financial literacy, secondary education (out of pocket microenterprise skills, enhancing and opportunity costs) is high for access to savings and expanding households in poverty. This suggests economic opportunities. Life skills the need for programs to reduce the should also be emphasized, for cost of education for disadvantaged example through ‘safe space clubs’ 110 Social Sector Note together with financial incentives to literacy, microenterprise skills, and attend. access to savings groups, as well as life skills, including a focus on These programs could look almost knowledge about reproductive like schooling to achieve some health, but in a culturally sensitive of the protective status against way to promote birth spacing and the early marriage provided by formal use of contraception. education. In the Niger context, this could be done by providing uniforms Again, more detailed work would resembling those worn by schoolgirls, be needed for Egypt to assess and ensuring that the clubs meet at whether these policy and program least three times a week for several suggestions for the Sahel would work, hours. Whether such measures would based on experiences such as that of be appropriate in Egypt’s context the program in Box 4. But the list is requires more detailed analysis, but a good starting point to think about appropriate measures could be taken options in light of the recent strategy as well. against child marriage adopted by Egypt’s government. Finally, for girls already married, programs could also offer financial Table 19: Target Groups and Interventions for Adolescent Girls – Illustrative Examples Source: Perlman et al. (2015). 111 Social Sector Note V. CONCLUSION program suggestions would work, the options mentioned may be a good One in six girls still marry before starting point to think about ways to the age of 18 in Egypt. It is often implement the strategy against child argued that child marriage has marriage recently adopted by Egypt’s serious negative impacts on a girls’ government. education. The estimates provided in this brief suggest that this is the case Box 4: The Ishraq (Sunrise) Program in Egypt. in Egypt Girls who married as children have Ishraq is a multi-dimensional program for on average substantially lower levels 12-to-15-year-old out-of-school girls that was launched in 2001 by the Population of education attainment. They have council. The program combined traditional a larger number of children over tested program elements (literacy, life their lifetime, thereby contributing to skills, nutrition) with more innovative ones population growth and comparatively (sports, financial education). Classes high rates of fertility in the country were held in youth centers, traditionally given its level of economic male-only spaces. Program staff focused development. Child marriage also on building a platform to support and leads to early childbirth which in turn institutionalize the program by educating has negative effects on their children, and mobilizing communities around leading to higher risks of under- issues of importance to adolescent girls. five mortality and stunting, among Over a decade Ishraq directly reached others. Because of lower education 3,321 girls and 1,775 boys in 54 villages, as well as over 5,000 girls’ parents, attainment, a larger number of boys, and community leaders across five children, and additional direct effects of the most disadvantaged governorates of child marriage on labor force in Upper Egypt. participation and earnings levels, child marriage reduces earnings for Evaluation of the program has shown women, and thereby the population that the program had a positive effect on as a whole. Finally, child marriage participants and communities. For girls, may be related to lower levels of program participation has improved happiness in married life. literacy, developed life skills, increased self-confidence, led to greater mobility A number of potential programs and and community participation, changed policies to prevent child marriage attitudes and behaviors, and built solidarity and social support among and keep girls in school have been girls who have traditionally been socially suggested based on international isolated. Some 81 percent of participants experience. While more detailed who took the national literacy exam work would be needed for Egypt to passed, with more than half of those assess whether these policy and girls joining formal schooling. At the 112 Social Sector Note community level, the Ishraq team has References worked extensively through community mobilization and home visits to change Malhotra,A.,A. Warner,A. McGonagle, parents’ and others’ traditional (or and S. Lee-Rife, 2011, Solutions restrictive) gender norms. to End Child Marriage: What the Evidence Shows. Washington, DC: It has created a ‘safe space’ in a traditionally male dominated venue, International Centre for Research on where adolescent out-of-school girls Women. can learn, play, and socialize, and it has increased girls’ visibility and status. Perlman, D., F. Adamu, and Q. Reflecting the positive achievements of Wodon, 2016, Child Marriage and Ishraq, demand for the program at the Girls’ Vulnerability in Niger: Insights community level has remained high with from Quantitative and Qualitative many mothers and community leaders Research, Washington, DC: The asking that the program continue and World Bank. that the upper age limit be increased to include older girls, even those who Selim, M., N. Abdel-Tawab, K. are married. At the institutional level, Elsayed, A. El Badawy, and H. El the program has increased buy-in from governorate and national-level Ministry Kalaawy, 2013, The Ishraq Program of Youth officials. for out-of-school girls: from Pilot to scale-up, Cairo: Population Council. While Ishraq has demonstrated significant achievements, the experience Nguyen, M. C., and Q. Wodon, of implementing and expanding the 2015, Global and Regional Trends program has also highlighted the in Child Marriage, Review of Faith & continuing challenges of changing International Affairs 13(3): 6-11. deep-rooted attitudes and behaviors, maintaining a permanent girls’ safe Nguyen, M. C., and Q. Wodon, space in youth centers, mainstreaming 2016, Impact of Child Marriage graduates, and replicating and on Education Attainment in Egypt, institutionalizing Ishraq. Programs, governments, and communities need to mimeo, Washington, DC: The World make long-term investments in order to Bank. achieve significant change at the village level. Wodon, Q., et al., 2015, Economic Impacts of Child Marriage: Preliminary Source: Selim et al. (2013). findings from analyses of existing data, Economic Impacts of Child Marriage Research Brief, ICRW and World Bank, Washington, DC. 113 Social Sector Note This note was prepared by a World Bank team as an input into a technical assistance task for Egypt’s Ministry of Finance. Comments from Caroline Krafft, Nistha Sinha, and participants at a review meeting for the note are gratefully acknowledged. Support from Gustavo Demarco for the preparation of this note is also gratefully acknowledged. Guidance was provided by Asad Alam. The note benefitted from partial funding from the Global Partnership for Education as part of a global research task on out of school children and disadvantaged groups. The opinions expressed in the notes and related studies are those of the authors only and need not represent the views of the World Bank, its Executive Directors, or the countries they represent. 114