Wednesday, January 29, 2020
Acupuncture as a nonconventional treatment for chronic neck pain Essay Example for Free
Acupuncture as a nonconventional treatment for chronic neck pain Essay Acupuncture as a nonconventional treatment for chronic neck pain Introduction            IntroductionNeck pain has been classified as one of the commonest problems among the people. This condition arises from various disorders or it may originate from tissues located at the neck (Hush, et al., (2009).The neck is also known as a cervical spine. The necks structure is characterized by vertebrae which run from the upper torso to the skull’s base. The stability of the spine is associated to ligaments and muscles that run along the vertebrae (National Institutes of Health. (2013). A neck’s main importance is its mobility and the support it accords to the head. It is prone to injuries because it is not offered much protection like the rest of the spine. Injuries normally cause less and restricted mobility and triggers NAIP. Unfortunately neck pain are not accorded seriousness, most people treat the neck pain as temporary. There are unique cases where the symptoms do not go away and hence diagnosis and corresponding treatment is required (American Academy of Orthopaedic Surgeons (2013).            Researchers (De Loose, V., Burnotte, F., Cagnie, B., Stevens, V., Van Tiggelen, D. (2008). have found out that the pains are caused by several factors such as wear and tear, sprains and abnormalities of the neck tissue. There is evidence of neck pains arising from other pains such as arm or shoulder pains (De loose, 2008). Normally activities such as extreme bends of the neck, falls and vehicle accidents can cause neck injuries. In certain situations damage of the neck can damage the spine causing paralysis. Researchers have also found out that Spondylosis which occurs in people above the age of 40, adds strains to neck joints creating a path for chronic neck pain. But the condition is treatable through both conventional and nonconventional methods.            Researchers and doctors have identified acupuncture as a nonconventional treatment method which is a very effective method for treating chronic neck pains. Researcher (Blosssfeldt, 2004), says that, acupuncture is gaining momentum as a popular nonconventional treatment method for chronic neck pain. He also adds that, the method has been well tolerated and has low risk of adverse effects. (Liang et al, 2008) says that, a combination of both traditional and modern acupuncture technique usually result in a documented and improved neck pain patterns. (Blossfeldt, 2004) adds that acupuncture is widely accepted and it is utilized as a complementary therapy useful in neck pain management originating from cervical spondylitis.            Researchers have carried out studies relating to acupuncture systematic review with an aim to find out on acupuncture effectiveness. The studies have found effectiveness evidence as inconclusive (salter et al, 2004). There are studies which have produced results which are positively favoring acupuncture and there are other results which have produced negative findings on the effective of the method (salter et al, 2004).            Due to the varying results, this research was developed to find out on the effectiveness of acupuncture method as a non-conventional method in treatment of chronic neck pains in relation to other research findings. In respect to national health statistics and reports, Survey data analysis can be used by medical professionals to measure the pain levels of patients before and after acupuncture treatment. Gathering results from various studies and comparing with the structures of acupuncture and preventive measures of neck pains can help us determine on the effectiveness of acupuncture as a treatment method. In this literature review the researcher will review on 1) how to establish the viability of acupuncture therapies in the treatment of chronic neck pain; 2) understanding of how sham, shallow and randomized acupuncture therapies are utilized in the treatment of chronic neck pain; 3)provide a conclusive evidence of the success of acupunctu re as an ideal method of relieving pain; 4)establish the effects of the three acupuncture therapies in the treatment of individuals with chronic pain of the neck; 5)offer recommendation of the viability of acupuncture as a treatment option that can be used by people with chronic neck pains. The researcher will also compare the duration of acupuncture treatment with other methods and also the cost associated and risk factors thereof.            METHODOLOGYTarget PopulationThe research data collected in this study focused on patients suffering from chronic neck pain. The individuals used in the research fell within the age of 21 and 55 years old. Although there are many patients who report about neck pain ailments in different health care facilities across the United States, patients withinthe ages of 21 and 55 years old were ideal for this research study. This was due to the fact that they were easier to track their progress of healing over a longer period of time. Elderly patients over the age of 55 years were not best placed in this research considering the various attributes in the healing processes of such people, which was proven to be relatively lower. Most of the data aboutindividuals with chronic pain of the neck was randomly collected in health care facilities in the State of California, United States. The majority of these patients were diagnosed with chronic neck pain and were put under a special focus while three acupuncture methods of therapies were performed(Witt 2004, p. 99). The study generally involved a thorough investigation of 191 patients in California’s health care. It is important to acknowledge that the various patients were deliberately initiated to acupuncture treatment as their decision to try the alternative medical practice after unsuccessful treatments in the mainstream medical procedures.            There were certainly no limitation on the sex of the patients; hence the research involved both male and female patients. Additionally, there was no specified number of male or females in the study, as patients, treatment and progress of treatment of patients was randomly taken. Further, it was assumed that both male and female patients presented similar responses to the different acupuncture therapies performed in the study(Sun et al, 2009, p. 850).The research was not limited by either ethnicity or race, although believed to have different characteristics in regard to various medical procedures.            Variables of the studyThe dependent variables in this study included the neck pain as an ailment caused by various aspects such as physical injury and disease or condition among others. The rates of cases involving chronic neck pains during the period of this study were generally unprecedented as the causes of such ailments greatly varied. Chronic neck pain among the patients varied in regard to the specific causes, which in this case included degenerative disc disease, neck injury, neck strain, herniated disc as well as pinched neck(Sun et al, 2009, p. 850). The first step in the treatment procedure involved a thorough diagnosis of common neck infections that caused the chronic pain. The research exploits treatment of such neck pains using acupuncture which falls into three categories including optimized acupuncture, shallow acupuncture and sham acupuncture.            Research LimitationsThe key limitations were based on neck pain due to common infection like virus infection of the neck and lymph nope swelling, as well as other infections such as tuberculosis of the neck, meningitis, and infection of spine bones around the neck. It was difficult in the study since some of patients did not present themselves on the day of the study. The study also used a large number of patients which was a challenge for the researcher. The different patients involved in this study had chronic neck pains attributed to extremely different causes, which included physical injuries, some rare infections, and virus infections among others(Witt 2004, p. 99). The patients with this problem are generally taken through the three acupuncture therapies, regardless of the cause of their condition(Hush 2004, p. 1533). The fact that all patients are uniformly taken into similar medical procedures without being categorized in relation to their specific cause of chronic neck pain remain as the greatest limiting attribute of this research. Additionally, time was a limiting factor since the time allowed for the research was not enough to efficiently tackle critically the objectives of the study.            Research criteria and Database usedIn this study, the items were collected through searching peer reviewed journal articles and therefore, the researcher thoroughly searched in various databases for article that provided information for patients suffering from chronic neck pains, specifically those individuals between the age of 21 and 55 years old. The researcher further categorized the data collected to form two groups of patients of the age bracket of 21 and 34 years and those between 35 and 55 years old. The creation of these two groups was essential as taking a wider range of people of ages 21 to 55 years old would present relatively a higher deviation in the healing processes of the patients, as those above the age of 35 years present a much longer period of healing as compared to the youthful 21 to 34 years group. The researcher focused the search on SPORT Discus, Academic Search Premier, BMJ Research Articles and Gov., database.            Keywords used in the studyThe key terms the researcher commonly used while searching for the relevant articles included: Chronic neck pain, cervical pain types of acupuncture, alternative medicine, Sham acupuncture, Shallow acupuncture and Randomized acupuncture.            OVERVIEW OF ACUPUNCTURE PRACTICEPracticing acupuncture started many centuries ago as a type of medication in China. It is the practice of implanting needles at certain points of the human skin as a form of therapy. In acupuncture practices, there is no involvement of drugs but only the needles are enough to accomplish the therapy (Liang et al, 8). The practice originated from China and has been noted to spread all over west of Europe (Liang et al, 8).As argued by the model on Chinese medicine, the specific places that the acupuncture needles are placed lies on the path named meridians where the dynamic energy goes through, hence allowing its access to control and regulate the flow of energy which is believed to be the cause of force imbalance (Willich et al, 2006, p. 98).            Populations and AcupunctureAcupuncture has been practiced in several parts globally, especially in Europe even though it is in its inception stages in the United States. According to NHI survey done in the year 2007 that also considered the use of CAM in America,where 1.4% of the respondents were found to be using acupuncture before then. The 3.1 million of the American population claimed they only practice it majorly for severe migraine and repetitive pain. The study showed that half of the respondents used acupuncture to treat chronic neck pain (Sun et al, 2009, p. 850).            The practice should obviously be regarded by physicians as an ideal treatment preference due to the backing it has received from those individuals who have used it in the treatment of chronic neck pain. Subsequently, the study did not restrict the adults basing on their gender due to limited research.            CHRONIC NECK PAINChronic neck pain is an ailment that is characterized by pain in the neck that lasts for an unusually long period of time, commonly over a period of three months(Blossfeldt, 2004). Although different from the common medical conditions of neck pains that last for only days, chronic neck pain is typically an ailment that takes even years without success in its treatment in the mainstream medical practices(Irnich, 2002). Chronic neck pain is usually associated with a number of disorders, as well as diseases that can involve any of the tissues around the neck(Witt 2004, p. 99). For instance, the common causes of this condition are strains of the neck, injury of the neck like a herniated disc, pinched disc, or whiplash, and degenerative disc disease. In addition, chronic neck pain is also linked to common infection like virus infection of the neck and lymph nope swelling, as well as other infections such as tuberculosis of the neck, meningitis, and infection of spine bones around the neck. Some patients also had chronic neck pains caused by extremely different causes, which include physical injuries, some rare infections, and virus infections among others. Further, chronic neck pain is also caused by certain infections like virus infection of the neck and lymph nope swelling, as well as other infections such as tuberculosis of the neck, meningitis, and infection of spine bones around the neck.            RISK FACTORS OF CHRONIC NECK PAINSChronic neck pain is generally caused by numerous factors ranging from physical injury to certain infections around the neck body tissues. Since neck pain affects the muscles around the body areas of the neck, it becomes painful to move the neck (De Loose, 2008, p. 475). In order to avoid or to prevent neck pains for the patients, it is always essential to consider staying away from activities may twist the neck and subsequently aggravate the already painful section of the neck(Witt 2004, p. 99). Therisk factors for the pain usually include injury from involvement in activities like motor vehicle accidents, horse riding, contact sports and bull riding among others, degeneration of cervical disc also known as Spondylitis, neck bent and twisting positions (De Loose, 2008, p. 475).In addition, it is also advisable to have activities that will enhance neck strengthening exercise, as well as neck bracing, reduc e TV watching usage of safety belts in motor vehicles and going to the gym for exercise.            TYPES OF ACUPUNCTURE USED IN CHRONIC NECK PAIN TREATMENTOptimized acupuncture therapyThe practice of optimized acupuncture therapy involves the utilization of traditional acupuncture, which is usually followed by intradermal needle therapy, commonly referred to as INT(Hush 2004, p. 1533). The use of OAT usually consists of the use of nine acupuncture points typically selected for an optimized acupuncture therapy group on the advice and consensus of the national expert committee of the OAT procedures. In this case, four points are subsequently located by physician intending to perform the OAT. The points selected are usually the cervical positive reactions planes found in the top and bottom of the cervical planes as well as horizontally away from the corresponding cervical vertebra(Witt 2004, p. 99). The study found that this type of acupuncture practice is highly sensitive and hence the need to be performed by an individual with more than five of practice experiences            Sham acupuncture therapyThe practice is put into use only as a tool for control in the scientific research in order to measure the efficiency of real acupuncture in various disease treatment. This type of acupuncture involves the use of skin penetrating shallow needles on the specified sham groups’ tender points.The tender points that are used in this method of acupuncture therapy are categorized as the key areas recommended for the acupuncture, which are the Ah Shee, also referred to as â€Å"oh yes point†. The points are crucial in this therapy and have to be used throughout the treatment procedure. Typically, the location of sham points is commonly defined by 25mm lateral extending to the standard location used for the OAT group.They include: the sham point of Dazhui (GV14) 25mm, which is 25 mm vertically below the usual standard GV14, sham points of (S115) Jianzhongshu and Huatuojiaji, which is 25 mm lateral to standard S 115 (Liang et al, 8). After the sham acupuncture, individuals undergoing the process or patients are treated through the use of point pressing (De Loose, 2008, p. 475). The findings show that a patient does not notice whether it is sham or real acupuncture being used. The results showed that the variation between real and sham practices are caused by habituation or the control effects. If the real acupuncture is efficient compared to the sham, then the habituation and control effects such as expectations of the patient, behavior and beliefs are present.            Shallow acupuncture therapyShallow acupuncture group undergoes similar procedures as the other OAT groups.However, the physicians are required to insert the needles in a vertical manner in order to reach the subcutaneous level at a specified depth of not more than 3 mm (Salter et al, 2004). Needle manipulation or any other sensation is prohibited in this particular group. Ultimately, after the shallow acupuncture, the patients are additionally treated by INT through the use of a similar method as in the other OAT groups. It was found that the therapy do not fully treat the pain fully due to its shallow penetration hence the need for additional treatment that follow the same procedures. It results to a more efficient treatment in comparison to other therapies though takes much time (Salter et al, 2004).            ACUPUNCTURE AS AN IDEAL METHOD COMPARED TO PHYSIOTHERAPYZhuang (2012); Robertshawe, (2008), compares the use of acupuncture and physiotherapy in the treatment of chronic neck pain in a research that took place in China. The research involved screening of a total of 310 patients. The patients were then randomly split into two equal groups, where one group was treated using acupuncture method, while the other group received treatment through physiotherapy. The outcome of the treatment of the two procedures revealed that patients treated under acupuncture procedures had better results in relieving neck pain, particularly after a period of three months. It is essential to acknowledge that physiotherapy is an alternative medical practice that can be used in the treatment of chronic neck pain. While acupuncture therapies generally used sterilizes needles that are usually inserted in the area around the neck depending on the type of acupuncture u sed, physiotherapy does not involve the use of needles. Physiotherapy utilizes several types of manipulation as well as exercise to relieve pain. The common illustration of the use of physiotherapy is the stretch, strengthen and straighten up exercise movements of the neck (Robertshawe, 2008; Willich, 2006).            EFFECTS OF ACUPUNCTURE TREATMENTWhite, (2001); Ji-Eun, (2010), researched about the adverse effects following a use of acupuncture to treat patients with chronic neck pain. In his survey, which included a prospective survey of 32,000 consultations with physiotherapists and doctors, the researcher, Adrian White aimed at ascertaining the incidence of adverse effects that are related to acupuncture treatment, as practiced by British doctors during that time. The research utilized data that were collected for the June of 1998 to February of 2000, from a total of 78 acupuncturists. Altogether the resulting significant effects were 43, subsequently giving only a rate of only 14 patients of the 10,000 patients included in the data. The results of this study showed that only 0.14 percent of the patients who used acupuncture in the treatment of chronic pain experience adverse effects (White, 2001). All the adverse effects were reported to have had cleared within the period of one week after the therapy. Similar diminishing effects were characterized at a longer period, except for only one incident that lasted for several weeks. The result derived from the data of acupuncture treatment did not report any serious adverse effects. The rates can only be classified as minimal considering that it was only 14 adverse effects out of the total 10,000 patients who were analyzed with the data provided (White, 2001; Ji-Eun, 2010). Generally, these effect rates do not give significant risk per individual patient.            RECOMMENDATION ON ACUPUNCTURE’S VIABILITYThe article by Chen, et al., (2010), offers exclusive views on acupuncture given by various physicians. The research by Chen among other authors who contributed to the article, there study targets collecting information that addresses the role of acupuncture in the management of pain in regard to opinions of physicians who manage such conditions. The research was conducted between 2007 and 2008 using a nationwide e-mail to 1083 physicians who were in active acupuncture practice in the United States. Chan et al., (2010) found that the overwhelmingly majority of the responders of the survey had a positive attitude and favorable experience of the use of acupuncture as an alternative modality in the management of chronic pain. The results of the survey subsequently indicate that acupuncture is considered effective by physicians in the management of chronic neck pain.            CASE STUDIES:Acupuncture for patients with chronic neck painWitt et al., (2006) undertook the study in examining how effective acupuncture as an alternative treatment for neck pain treatment in comparison to patients who used routine medical care. The study used a random approach of more than 14000 individuals aged above 18 suffering from neck pain symptoms within a period of 6 months. Also took a non-acupuncture for 15 sessions within a period of 3 months. The acupuncture category were given injections without any other acupuncture treatment. The group which was controlled was not treated using acupuncture but both groups could use any other mode of treatment. The study found out that patients using routine care and add on acupuncture treatment showed significant improvements in both pain and quality of their lives in comparison to patients who only used routine treatments. Therefore, the results concludes that acupuncture can be used alo ngside routine treatments to achieve optimal results.            Efficacy and safety of acupunctureVas, et al, (2006) conducted a study to establish the effectiveness of acupuncture vis a vis placebo. Both methods were to be utilized to treat chronic neck pains that were not complicated. (N=123) patients, who were over the ages 17 and who possessed chronic neck pains for over 3 months were used. They were randomly selected into 2 groups, the acupuncture group and placebo group. For 3 weeks, the acupuncture group was treated with 5 acupuncture treatments. The treatment characteristics were, 30 minutes treatment followed by 10 minutes manual treatments. While the placebo group was subjected to transcutaneous nerve stimulation, which was characterized by 30 minutes of treatment and the potentiometer was being adjusted after every 10 minutes.            The findings from this study were that, acupuncture as a form of neck treatment had minimal side effects. For overall effectiveness, acupuncture was found to have higher effectiveness than placebo. Researchers conclusively said that, acupuncture was effective.            DISCUSSIONIn its broad context, this research has dwelled in covering all the related material on acupuncture and especially its effectiveness in treatment of acupuncture. Most are the studies which have found considerable effectiveness and a few studies have found less significant improvement in acupuncture use. The researchers (salter et al, 2006; Liang et al 2012; Chen et al 2010; vas et al 2006) have favorably recognized acupuncture as an effective non-conventional treatment method.            From the review above, it is evident that all the methods of acupuncture are effective in treatment of chronic neck pains. Sham, optimization and shallow acupuncture all have a capacity of effectiveness when administered well. The various studies by salter have provided solid practical evidence and information on patients’ health upon using all the three types of acupuncture in treatment of patients and individuals (salter et al 2004). For example in 2007, a national health interview survey in America found that, 1.4% of respondents have used acupuncture to treat chronic neck pains. That percentage reported success, which is a testament to acupunctures effectiveness (National Center for Complementary and Alternative Medicine 2012).            (Blossfeldt, 2004) in his research notes that, acupuncture optimized technique success rate was a favorable 68%. Blossfeldt also noted that, on short term basis, acupuncture was 78% effective, while on long term basis it was 49% effective. Salter also found out on effectiveness of acupuncture. The neck pain questionnaire that he used for a period of 3 months, found out that, of the 34 % of the patients who have neck pains, 14% of these have effectively used acupuncture therapy (salter et al 2004) another researcher Liang, who conducted studies in china in association with other scholars, they found out that optimized acupuncture as a method of treating chronic neck pains was very effective.            Although I extensively performed research on a wide range of databases, there are some articles that may have been missed out. Since I was individually conducting this research alone, it is possible that the large number of crucial articles were subsequently overlooked. In addition, there are many external factors that could have influenced the entire result of the use of acupuncture as an ideal treatment for chronic neck pain. The majority of studies slightly differ in a number of issues such as data collected, population, or any of combinations of these factors. White (2001) precisely researched about the adverse events following a use of acupuncture to treat patients with chronic neck pain, with an extreme number of respondents. Chen, L. et al., (2010), had a relatively smaller number of responders, and also had collection of data to be collected only through email in his research on the effectiveness of acupuncture in the management of chronic pain in the neck. These are some of the factors that were out of the scope of the research, hence determining the effectiveness of acupuncture was difficult, since the aspect of effectiveness could easily be isolated from some external factors.            The analysis of the specific information provided by the studies of the literature review of this research paper indicates that either of the three methods of acupuncture can effectively treat the chronic neck pain. The procedural practice of sham, shallow and optimized acupuncture, though different, they present similar way of performing the acupuncture therapy, equally offering effective treatment for chronic neck pain. Liang et al, (2012) asserts that the three types of acupuncture to be based on the thought that decrease or alienation of pain can be enhanced by releasing the chemicals responsible for blocking pain. Issues of age in the study have been considered as the research only focused on individuals between 21 years old and 55 years, as they are likely to have a faster period of healing as compared to adult elderly groups of more than 55 years old. Generally, the use of acupuncture is illustrated as effective as it has previously been used to treat patients with chronic neck pain.            The loopholes evident in the research include the possibility of a prior knowledge in determining the differences that may emerge upon consideration for gender in the treatment program. In the entire study, there is no single explanation of the ratio of females against the males in finding out the effectiveness of acupuncture treatment procedures. The study focused on a general perspective of patients with chronic neck pain regardless of their respective sex or gender. The knowledge of the differences that exist between males and females could have some effects on the understanding the use of acupuncture. In addition, the paper did not focus on the causes of the various neck pain, which could also compromise the results of the study, considering that such plans are typically attributed to a wide variety of causes.            Topics that can be considered for further research are establishing the element of gender in determining the effectiveness of acupuncture while treating chronic neck problem. The various studies illustrated in the research paper did not point out the importance of understanding differences in the healing process of male and female patients with chronic neck pain. I suggest a study be conducted with a major emphasis on the aspect of gender differences between patients in order to determine the effectiveness of acupuncture treatment for neck pain in male and female patients. If this study is conducted, it will be possible to compare the effectiveness of acupuncture treatment between male and female patients within the same health condition of chronic neck pain. References Blossfeldt, P. (2004). Acupuncture for Chronic neck pain: a cohort study in an NHS pain Clinic.22(3): 146-151. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15551941Chen, L., Houghton, M., Seefeld, L., Malarick, C. Mao.Jianren. (2010). A Survey of SelectedPhysician Views on Acupuncture in Pain Management. 11(4), 530-534 Salter, G.C, Roman, M., Bland, M. J MacPherson, H. (2006). Acupuncture for chronic pain: apilot for randomized controlled trial. 7(1): 3-14. Retrieved fromhttp://www.biomedcentral.com/1471-2474/7/99 Liang, Z. H., Di, Z., Jiang, S., Xu, S. J., Zhu, X. P., Fu, W,. Lu, A. P. (2012). The optimizedacupuncture treatment for neck pain caused by cervical spondylosis: a study protocol of amulticenter randomized controlled trial. 13(1): 2-18. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/22776567 American Academy of Orthopaedic Surgeons.(2013). neck pain. Retrieved fromhttp://orthoinfo.aaos.org/topic.cfm?topic=a00231Chen, L., Houghton, M., Seefeld, L., Malarick, C., Mao, J. (2010).a survey of selected physician views on acupuncture in pain management. Pain Medicine, 11(4), 530-534. Retrieved from SPORTDiscus. De Loose, V., Burnotte, F., Cagnie, B., Stevens, V., Van Tiggelen, D. (2008). Prevalence and risk factors of neck pain in military office workers. Military Medicine, 173(5), 474-479. Retrieved from Academic Search Premier. Hush, J. M., Michaleff, Z., Maher, C. G., Refshauge, K. (2009). Individual, physical and psychological risk factors for neck pain in Australian office workers: a 1-year longitudinal study. European Spine Journal, 18(10), 1532-1540. Retrieved from Academic Search Premier. Irnich, D., Behrens, N., Gleditsch, J. M., Stà ¶r, W., Schreiber, M. A., Schà ¶ps, P., Beyer, A. (2002). Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain (03043959), 99(1/2), 83.Retrieved from Academic Search Premier. Ji-Eun, P., MyeongSoo, L., Jun-Yong, C., Bo-Young, K., Sun-Mi, C. (2010). Adverse Events Associated with Acupuncture: A Prospective Survey. Journal Of Alternative Complementary Medicine, 16(9), 959-963. Retrieved by Academic Search Premier. National Center for Complementary and Alternative Medicine. (2012). Acupuncture: an introduction. Retrieved from http://nccam.nih.gov/health/acupuncture/introduction.htmNational Institutes of Health.(2013). neck pain.Retreived from http://www.nlm.nih.gov/medlineplus/ency/article/003025.htmRobertshawe, P. (2008). Acupuncture and physiotherapy for neck tension.Journal Of The Australian Traditional-Medicine Society, 14(3), 187. Retrieved from Academic Search Premier. Sun, M., Hsieh, C., Cheng, Y., Hung, H., Li, T., Yen, S., Huang, I. (2010). The therapeutic effects of acupuncture on patients or individuals with chronic neck myofascial pain syndrome:: a single-blind randomized controlled trial. American Journal Of Chinese Medicine, 38(5), 849-859. Retrieved from Academic Search Premier. Vas, J., Perea-Milla, E., Mà ©ndez, C., Navarro, C., Leà ³n Rubio, J., Brioso, M., Obrero, I. (2006). Efficacy and safety of acupuncture for chronic uncomplicated neck pain: A randomised controlled study. Pain (03043959), 126(1-3), 245-255. Retrieved from Academic Search Premier. White, A. (2001). Adverse events following acupuncture: prospective survey of 32,000 consultations with doctors and physiotherapists. 10(1), 3-14 Retrieved from BMJ Research Articles Willich, S. N., Reinhold, T., Selim, D., Jena, S., Brinkhaus, B., Witt, C. M. (2006).Cost-effectiveness of acupuncture treatment in patients or individuals with chronic neck pain.Pain (03043959), 125(1/2), 107-113. Retrieved from Academic Search Premier Witt, C. M., Jena, S., Brinkhaus, B., Liecker, B., Wegscheider, K., Willich, S. N. (2006). Acupuncture for patients or individuals with chronic neck pain. Pain (03043959), 125(1/2), 98-106. Retrived from Academic Search Premier. Source document
Tuesday, January 21, 2020
Hope in The Sun also Rises Essay -- Essays Papers
Hope in The Sun also Rises WWI consumed the lives of millions. Those who lived through the war may have had only minor physical injuries or perhaps they were lucky enough to get away unharmed, but all of those who went home in the 1920s had lost an important feature in their life which was the importance of hope. The lack of hope hurt all the characters who experience the war in one way or another. Which, led to love being an empty word to the affected characters. These affected characters search for happiness in sex and in drunkenness and in superficial human relationships for the fulfillment that they were missing. Robert Cohn was about the only one who showed some kind of hope, but this hope seemed to bother the other characters. Of course the hope that Cohn demonstrated was that of hoping for some kind of respond from Brett. Robert Cohn was probably not even capable of truly being in love. He had severe self-esteem problems in college. "He took it out in boxing, and he came out of Princeton with painful self-consciousness and the flattened nose, and was married to the first girl who was nice to him."(4) Cohn was looking for love and thought he could find it in a girl who would care for him. All of the characters seem to be dealing with this same issue. Cohn, however, dealt with his problems in a different way. "He cared nothing for boxing, in fact he disliked it, but he learned it painfully and thoroughly to counteract the feeling of inferiority an... Hope in The Sun also Rises Essay -- Essays Papers Hope in The Sun also Rises WWI consumed the lives of millions. Those who lived through the war may have had only minor physical injuries or perhaps they were lucky enough to get away unharmed, but all of those who went home in the 1920s had lost an important feature in their life which was the importance of hope. The lack of hope hurt all the characters who experience the war in one way or another. Which, led to love being an empty word to the affected characters. These affected characters search for happiness in sex and in drunkenness and in superficial human relationships for the fulfillment that they were missing. Robert Cohn was about the only one who showed some kind of hope, but this hope seemed to bother the other characters. Of course the hope that Cohn demonstrated was that of hoping for some kind of respond from Brett. Robert Cohn was probably not even capable of truly being in love. He had severe self-esteem problems in college. "He took it out in boxing, and he came out of Princeton with painful self-consciousness and the flattened nose, and was married to the first girl who was nice to him."(4) Cohn was looking for love and thought he could find it in a girl who would care for him. All of the characters seem to be dealing with this same issue. Cohn, however, dealt with his problems in a different way. "He cared nothing for boxing, in fact he disliked it, but he learned it painfully and thoroughly to counteract the feeling of inferiority an...
Monday, January 13, 2020
Health System in Egypt
Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Contents F O R E W O R D †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 5 1 E X E C U T I V E S U M M A R Y †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 2 S O C I O E C O N O M I C G E O P O L I T I C A L M A P P I N G †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 11 2. 1 Socio-cultural Factors †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢ € ¦Ã¢â‚¬ ¦ 1 2. 2 Economy †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 11 2. 3 Geography and Climate †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 12 2. 4 Political/ Administrative Structure †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 12 3 H E A L T H S T A T U S A N D D E M O G R A P H I C S †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 14 3. 1 Health Status Indicators †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 4 3. 2 Demography †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 15 4 H E A L T H S Y S T E M O R G A N I Z A T I O N †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 17 4. 1 Brief History of the Health Care System †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 17 4. 2 Public Health Care System †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 4. 3 Private Health Care System†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 20 4. 4Overall Health Care System †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 21 5 G O V E R N A N C E /O V E R S I G H T †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 23 5. 1 Process of Policy, Planning and management †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 23 5. 2 Decentralization: Key characteristics of principal types †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 24 5. 3 Health Information Systems†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 27 5. 4 Health Systems Research†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 8 5. 5 Accountability Mechanisms †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 28 6 H E A L T H C A R E F I N A N C E A N D E X P E N D I T U R E †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 29 6. 1 Health Expenditure Data and Trends †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 29 6. 2 Tax-based Financing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚ ¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 32 6. 3 Insurance †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 33 6. 4Out-of-Pocket Payments †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 40 6. 5 External Sources of Finance †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 41 6. 6 Provider Payment Mechanisms †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 41 7 H U M A N R E S O U R C E S †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 45 7. 1 Human resources availability and creation †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 45 7. 2 Human resources policy and reforms over last 10 years†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 55 8HEALTH SERVICE DELIVERY†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 59 8. 1 Service Delivery Data for Health services †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 59 8. 2 Package of Services for Health Care †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 63 8. 3 Primary Health Care †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 63 8. 4 Non personal Services: Preventive/Promotive Care †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 75 8. 5 Secondary/Tertiary Care †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 8. 6 Long-Term Care †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 90 8. 7 Pharmaceuticals †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚ ¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 89 8. 8 Technology †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 100 9 HEALTH SYSTEM REFORMS†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 101 9. 1 Summary of Recent and planned reforms †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 101 10REFERENCES †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 107 11. ANNEXES †¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 11. 1 Ministry of Health and Population Organogram†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 1 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO List of Tables Table 2. 1 Socio-cultural indicators Table 2. 2 Economic Indicators Table 2. 3 Major Imports and Exports Table 3. 1 Indicators of Health status Table 3. 2 Indicators of Health status by Gender and by urban rural 2006Table 3. 3 Top 10 causes of Mortality Table 3. 4 Demographic indicators Table 3. 5 Demographic indicators by Gender and Urban rural Table 6. 1 Health Expenditure Table 6. 2 Sources of finance, by percent Table 6. 3 Health Expenditures by Category Table 6. 3. 1. Health care financing i n Egypt: coverage, eligibility and benefits Table 6. 4 Population coverage by source Table 6. 4. 1 Distribution of HIO beneficiaries by law (1995–2002) Table 6. 4. 2 Comparison between 2002 and 1995 estimates Table 6. 4. 3 Comparative expenditures and subsidies from MOF to hospital services, financial year 2004/2005Table 6. 4. 4 Performance Indicators Table 7. 1 Health care personnel Table 7. 1. 1 Staff registered with syndicates Table 7. 1. 2 Comparison of staff registered and in post in MOHP, December 2005 Table 7. 1. 3 Staff registered and in post in MOHP plus percentage increase in difference over 20 years Table 7. 1. 4 Physicians and nurses by health sector (%) Table 7. 1. 5 Geographical distribution of MOHP physicians and nurses Table 7. 1. 6 Distribution of physicians and nurses by governorate per 100,000 population (2005) Table 7. 2 Human Resource Training Institutions for Health Table 8. 1Service Delivery Data and Trends Table 8. 1. 1 Improvement in hospital based se rvices (1996–2005) Table 8. 1. 2 Distribution of health facilities across Egypt (2006) Table 8. 1. 3 Distribution of health care workers in Egypt (2006) Table 8. 1. 4 Comparison of specialists (2005) Table 8. 1. 5 Comparison of specialists (2005) Table 8. 1. 6 Comparison of MOHP and HIO registered and in post personnel2005 Table 8. 1. 7 Distribution of physicians with private clinics by number of jobs (%) 2 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Table 8. 1. 8 Governorates distribution according to phasesTable 8. 1. 9 Basic preventive and promotional public health services Table 8. 2 Inpatient use and performance Table 8. 2. 1 National distribution of inpatient beds by type of facility (2005) Table 8. 2. 2 Change in hospital beds by type of provider (1991, 1997, 2001) Table 8. 2. 3 MOHP strategy (1997, 2001, 2017) Table 8. 2. 4 Distribution of physicians among some service providers (2002) Table 8. 2. 5 Bed distribution by health provider in go vernorates Table 8. 2. 6 Beds/population by governorate and type of provider (2005) Table 8. 2. 7 Private sector providers (2005) Table 8. 2. 8Private sector services (2002) Table 8. 7 expenditure by type of provider and ownership (2005) 3 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO List of Figures Figure 1 Uses of health resources, by categories of providers Figure 2 Sources of revenues for the health sector, 1995 Figure 3 Distribution of HIO beneficiaries by law (1995–2002) Figure 4 Distribution of physicians and nurses by governorate per 100,000 population (2001) Figure 5 Beds per populations in governorates Figure 6 Growth trends in the pharmaceutical market Figure 7 Expected value of the market size in 2010Figure 8 Trend in drug consumption as expenditure per capita Figure 9 Drug expenditure in private and governmental sector Figure 10 Distribution of drug consumption by therapeutic category (2001–2002) 4 Health Systems Profile- Egypt R egional Health Systems Observatory- EMRO F OREWORD Health systems are undergoing rapid change and the requirements for conforming to the new challenges of changing demographics, disease patterns, emerging and re emerging diseases coupled with rising costs of health care delivery have forced a comprehensive review of health systems and their functioning.As the countries examine their health systems in greater depth to adjust to new demands, the number and complexities of problems identified increases. Some health systems fail to provide the essential services and some are creaking under the strain of inefficient provision of services. A number of issues including governance in health, financing of health care, human resource imbalances, access and quality of health services, along with the impacts of reforms in other areas of the economies significantly affect the ability of health systems to deliver.Decision-makers at all levels need to appraise the variation in health system perfor mance, identify factors that influence it and articulate policies that will achieve better results in a variety of settings. Meaningful, comparable information on health system performance, and on key factors that explain performance variation, can strengthen the scientific foundations of health policy at national, regional and international levels.Comparison of performance across countries and over time can provide important insights into policies that improve performance and those that do not. The WHO regional office for Eastern Mediterranean has taken an initiative to develop a Regional Health Systems Observatory, whose main purpose is to contribute to the improvement of health system performance and outcomes in the countries of the EM region, in terms of better health, fair financing and responsiveness of health systems.This will be achieved through the following closely inter-related functions: (i) Descriptive function that provides for an easily accessible database, that is co nstantly updated; (ii) Analytical function that draws lessons from success and failures and that can assist policy makers in the formulation of strategies; (iii) Prescriptive function that brings forward recommendations to policy makers; (iv) Monitoring function that focuses on aspects that can be improved; and (v) Capacity building function that aims to develop partnerships and share knowledge across the region.One of the principal instruments for achieving the above objective is the development of health system profile of each of the member states. The EMRO Health Systems Profiles are country-based reports that provide a description and analysis of the health system and of reform initiatives in the respective countries. The profiles seek to provide comparative information to support policy-makers and analysts in the development of health systems in EMRO.The profiles can be used to learn about various approaches to the organization, financing and delivery of health services; descri be the process, content, and implementation of health care reform programs; highlight challenges and areas that require more in-depth analysis; and provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in different countries.These profiles have been produced by country public health experts in collaboration with the Division of Health Systems & Services Development, WHO, EMRO based on standardized templates, comprehensive guidelines and a glossary of terms developed to help compile the profiles. A real challenge in the development of these health system profiles has been the wide variation in the availability of data on all aspects of health systems. The profiles are based on the most authentic sources of information available, which have been cited for ease of reference. For maintaining consistency and comparability in the sources of 5Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO information, efforts have been made to use as a first source, the information published and available from a national source such as Ministries of Health, Finance, Labor, Welfare; National Statistics Organizations or reports of national surveys. In case information is not available from these sources then unpublished information from official sources or information published in unofficial sources are used. As a last resort, country-specific information published by international agencies and research papers published in international and local journals are used.Since health systems are dynamic and ever changing, any additional information is welcome, which after proper verification, can be put up on the website of the Regional Observatory as this is an ongoing initiative and these profiles will be updated on regular intervals. The profiles along with summaries, template, guidelines and glossary of terms are available on the EMRO HSO website at www. who. int . healthobservatory It is hoped the member states, international agencies, academia and other stakeholders would use the information available in these profiles and actively participate to make this initiative a success.I would like to acknowledge the efforts undertaken by the Division of Health Systems and Services Development to help countries of the region in better analyzing health system performance and in improving it. Regional Director Eastern Mediterranean Region World Health Organization 6 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 1 E XECUTIVE S UMMARY Egypt is going through a demographic and epidemiological transition that is affecting both the size and health status of the population. The population growth rate has fluctuated from a low of 1. 92% a year during 1966–1967, to 2. 5% annually during 1976–1986, later declining to 2% a year during 1980–1993 and 2. 1% annually in 2001. Changes in fertility and mortality rates ha ve been the major source of population growth in Egypt. The population pyramid has a wide base with children aged under 15 representing 37% of the population, reflecting relatively high fertility in recent years. The proportion of children aged under 10 years is smaller than the proportion aged 10–14 years. The rate decreased from 80 in 1988 to 69 in 2000, so the proportion of productive group aged 15–64 years has increased.The average age of the population has risen, with a life expectancy from birth of 65. 5 years for males in 1996 to 69. 2 years in 2006. It is higher for women than for men (69. 2 and 73. 6 years, respectively). Egypt is a lower-middle-income country with a per capita gross national product (GNP) that doubled between the years 1993 and 1999, from US $600 to $1200 (DHS, 2000). The Egyptian economy has witnessed a turnaround in growth performance following a period of economic slow-down that started in 1986.The adoption of the open door policy in 1975 afforded the Egyptian economy a decade of rapid economic growth, supported by large inflows of foreign assistance, workers’ remittances, and oil and tourism revenues. The drop in oil prices in 1986 signaled the end of a decade of economic boost, underscoring the volatility of Egypt’s key revenues sources and the constraints of an inward-oriented growth strategy. With the success of the stabilization program in achieving its objectives, Egypt has been successful in reversing the slow growth rates that characterized the period 1991–1995.Real GDP grew annually at an average of 3. 8% during 1993–1996 and at an average of 6% during 1996–1998. Inflation has been brought down from a peak of 21% in 1992 to 7% in 1996 and 3. 6% by 2000 (UNDP, 2000). While public expenditure on health in terms of budget share appears to be low in Egypt, overall spending at 3. 7% of GDP is also low, when compared to other comparable income countries. The Ministry of Health an d Population (MOHP) budget, as part of the entire Government budget, increased from 2. 2% in 1995/1996 to 3. % in 2000/2001 and the MOHP expenditure per capita increased from LE26. 8 in 1996 to LE56. 7 in 2001. The health financing system in Egypt today manifests significant systemic inefficiencies and inequities that severely limit the effectiveness of the health system as a whole. Any attempts to expand the scope of services or increase the revenues and expenditures on health care without first addressing these systemic bottlenecks in the health financing system will result in further exacerbating the inefficiencies and inequities in the system.The existing system of health financing mechanisms in place today, whether it is through the general revenues Ministry of Finance or the Health Insurance Organization system or through private spending, establishes a regressive pattern of resource mobilization and resource allocation. Inequities are evident across many dimensions, in terms of income levels, gender, geographical distribution (rural and urban, and by governorate levels), and health outcomes. 7 Health Systems Profile- Egypt Regional Health Systems Observatory- EMROThe coverage of the Egyptian population with the National Health Insurance scheme is increasing through the addition of new population groups under the umbrella of social health insurance, for example school children and newborn children. In the year 1980, the coverage was 4% of the total population, and it doubled in 1990. In the year 1995, it reached 36% and increased over the last ten years to 45%. Out of pocket spending has been rising over past decade and currently stands at 62%. HIO does not reach 80% of the private sector workforce.Highest governmental healthcare spend is proportionately in lowest income quintile. The 1952 Constitution pronounced free medical care as a basic right for all Egyptians. The Government has been the sole provider and financier of all primary/preventive and mos t inpatient curative care in Egypt. However, over the past two decades governmental budgetary constraints have resulted in relatively stagnant health expenditures. The structural adjustment program has also reduced the government's resource position vis-a-vis allocation for social services sectors in general, and health services in particular.The Egyptian health system has a pluralistic nature with a wide range of health care providers competing and complementing each other, allowing clients freedom of choice when seeking care according to their needs and ability to pay. However, the Government is committed to providing health care to poor and unprivileged population groups. Parallel to, and related to, its demographic transition, Egypt is currently facing an epidemiological transition that is characterized by:  ¦ Reduced mortality rates among infants and children from diarrhea, immunization-preventable diseases and respiratory infections. Rising prevalence of risk factors such as obesity, smoking and hypertension, responsible for chronic diseases.  ¦ A changing socioeconomic environment leading to different diets, increased industrialization, and increased motor vehicle traffic accidents. The distribution of the burden of diseases has changed from a predominance of infectious and parasitic diseases to a different mortality pattern whereby cardiovascular diseases are currently the leading cause of mortality (45% in 1991, compared to 12% in 1970 and 6. 3% in 2001).Egypt is therefore affected by a dual burden of disease, thus associating the morbidity and mortality patterns of developing countries with those induced by modernization. As a result of the demographic and epidemiological transition, the major health and population challenges are: 1. Population growth 2. Burden of endemic and infectious diseases 3. Maternal, infant and childhood mortality 4. Burden of chronic diseases, renal failure and cancer 5. Injuries and accidents 6. Smoking, other addiction s, and their complications 7. Disabilities and congenital anomalies 8 Health Systems Profile- EgyptRegional Health Systems Observatory- EMRO 8. Human resources (capabilities, skills, knowledge, allocation, salaries and incentives) 9. Infrastructure (buildings, equipment, furniture and maintenance) 10. Basic public services (housing, unplanned areas and slums, potable water, sewage disposal). The health system has significant strengths and weaknesses resulting from its continuing evolution. The performance of the sector with respect to health services, human resources, physical infrastructure, financing, organization and management, and the pharmaceutical sector will be assessed in following eight sections.Ministry of Health and Population has decided on a reform program based on the strengths of the current system, while at the same time rectifying its weaknesses. The Government of Egypt has embarked on a major restructuring of the health sector. This reform was deemed necessary bec ause the MOHP and its main partners had identified fragmentation in the delivery of health services, excessive reliance specialist care and low primary care service quality as the main constraints to achieving universal coverage.The Egyptian Health Sector Reform Program (HSRP) was officially launched in 1997. The World Bank (WB) started its contribution by designing the Master Plan for Montazah Health District in Alexandria Governorate, in May 1998. By the following year, in 1999, United States Agency for International Development (USAID) was the first donor to begin field-level operations, while the European Commission (EC) joined the HSRP in November 1999. The African Development Bank (ADB) initiated its work through designing Master Plans for three health districts in June 2003.The most recent partner at HSRP is the Austrian Government, which directs its participation to improving the district hospitals as part of health district approach. The overall aim of the HSRP is twofold. Firstly to introduce a quality basic package of primary health care services, contribute to the establishment of a decentralized (district) service system and improve the availability and use of health services. Secondly to introduce institutional structural reform based on the concept of splitting purchasing/providing and the regulatory functions of the Ministry of Health and Population.Coverage would be provided by a National Social Insurance System. The ultimate goal of health sector reform initiatives is to improve the health status of the population, including reductions in infant, under-five, maternal mortality rates and population growth rates and the burden of infectious disease. The HSRP has meanwhile initiated a new primary care strategy in accredited facilities, known as Family Health Units (FHU’s). Facilities are being contracted by a purchasing agency -the Family Health Fund (FHF) – to provide services to the population.It is envisaged that the HSRP will g radually extend its scope to the secondary level by establishing â€Å"District Provider Organizations†. The FHF will consequently develop in the direction of a full purchasing agency of services from the public and private sector. The newly introduced Family Health Model (FHM) constitutes one of the cornerstones of the reform program. It brings high quality services to the patient and will integrate most of the vertical programs into the Basic Benefit Package of services.To date the FHM has been introduced in 817 health facilities, which present 18% of the total public primary health care facilities. HSRP has an ambitious five years plan, by the end of year 2010, to cover the entire public primary health care facilities with the Family Health Model. The Egyptian Health Sector Reform Program went through several stages, including the preparatory stage from 1994 to 1996. During this stage, several valuable studies were conducted and used later to develop the â€Å"Strategies for Health Sector Change†study. 9 Health Systems Profile- Egypt Regional Health Systems Observatory- EMROThis was an analytical report on the Egyptian health sector. Designing the health Master Plans stage for the three pilot governorates followed this. Experimenting stage of the Family Health Model took place in one of the primary health care facilities, which took about two years to implement. This was followed by piloting stage of the Model in three governorates followed by another two governorates and included activities such as: Building staff pattern, designing the contents of the Basic Benefits Package and Essential Drug List, and other components of the Family Health Model.The Program has shifted its strategy in March 2003 from health facility oriented approach to the district approach, which was called the District Provider Organization. As of 2005, the HSRP has gradually expanded its operations to ten additional governorates, pushing the total number of involved gov ernorates to 15, which presents more than 50% of the country coverage.The Health Reform Program has three main components; (1) Service component as seen in the Family Health Mode, (2) Mandate role and functions of the Ministry of Health and Population, and (3) Introduction of a sustainable universal health insurance system. It is envisaged that all three goals and objectives can be achieved in an Integrated District Health System model. All the necessary elements are available and the Sector for Technical Support and Projects (STSP) is in developing process for an integrated health system based on a district that is evaluated internally and externally and be replicable.The Integrated District Health System (IDHS) is the district that covers the following criteria; (1) fully implements the District Provider Organization, (2) has financial sustainability, (3) separates providing from financing of health services, (4) implements the content of the district health coverage plan, (5) pro vides basic benefits and secondary care packages through public, private and NGO, (6) and applies quarterly measures for the achievements of HSRP’s five objectives. 10 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 2 S OCIO E CONOMIC G EOPOLITICAL M APPING 2. Socio-cultural Factors Table 2-1 Socio-cultural indicators Indicators 1990 1995 2000 2004 – – – – Literacy Total: 48. 8 (92) 57. 7 (98) 67. 4 (02) 69. 4 02) Female Literacy to total literacy: 35. 3 (92) 65. 9 (98) 63. 4 (01) 67. 4 02) Women % of Workforce 29. 2(93) 18. 0(96) 18. 5(01) 21. 8(02) Primary School enrollment 98. 0(92) 98. 5(98) 91. 7(01) 99. 2(02) % Female Primary school pupils 80. 4(92) 84. 5(98) 93. 2 107. 1(02) %Urban Population 44. 0(86) 43. 0(96) 42. 8 57. 6 Human Development Index: Source: NICHP Report, Ministry of Health and Population, 2005. Egypt Human Development Report, 1995, 1999, 2003, 2004. . 2 Economy Key economic trends, policies and reforms Lack of substantial progress on economic reform since the mid 1990s has limited foreign direct investment in Egypt and kept annual GDP growth in the range of 2%-3% in 200103. However, in 2004 Egypt implemented several measures to boost foreign direct investment. In September 2004, Egypt pushed through custom reforms, proposed income and corporate tax reforms, reduced energy subsidies, and privatized several enterprises. The budget deficit rose to an estimated 8% of GDP in 2004 compared to 6. 1% of GDP the previous year, in part as a result of these reforms.Monetary pressures on an overvalued Egyptian pound led the government to float the currency in January 2003, leading to a sharp drop in its value and consequent inflationary pressure. In 2004, the Central Bank implemented measures to improve currency liquidity. Egypt reached record tourism levels, despite the Taba and Nuweiba bombings in September 2004. The development of an export market for natural gas is a bright spot for futu re growth prospects, but improvement in the capital-intensive hydrocarbons sector does little to reduce Egypt's persistent unemploymentTable 2-2 Economic Indicators Indicators 1990 GNI per Capita (Atlas method) current US$ 2000 2004 NA GNI per capita (PPP) Current International Real GDP Growth (%) 1995 1. 9 (91-92) 5 (95-96) 3. 4 (00-01) 4 (03-04) 11 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Real GDP per Capita ($) (91- 92) 769 1,285 1,036 9. 2 (91-92) Unemployment % (estimates) 1,143 9. 6 (91-92) 9. 0 (01) 10. 2 (03) Source: Egypt Human Development Report, 2003. Ministry of Foreign Trade, Egypt, Monthly Economic Digest, February 2005. Table 2-3 Major Imports and Exports Major Exports:Crude oil and petroleum products, cotton, textiles, metal products and chemicals. Major Imports Machinery and equipment, foodstuffs, chemicals, wood products and fuels. 2. 3 Geography and Climate Map of Egypt Arab Republic of Egypt is located at the northern Africa, border ing the Mediterranean Sea, between Libya and the Gaza Strip, and the Red Sea north of Sudan, and includes the Asian Sinai Peninsula. Total area is 1,001,450 sq km (land: 995,450 sq km, water: 6,000 sq km). A total of 2,665 km border countries: Gaza Strip 11 km, Israel 266 km, Libya 1,115 km, Sudan 1,273 km.Coastline is 2,450 km. The climate is desert; hot, dry summers with moderate winters. Natural resources; petroleum, natural gas, iron ore, phosphates, manganese, limestone, gypsum, talc, asbestos, lead and zinc. 2. 4 Political/ Administrative Structure The chief of state is the President, head of government is the Prime Minister. Bicameral system consists of the People's Assembly or Majlis al-Sha'b (454 seats; 444 elected by popular vote, 10 appointed by the president; members serve five-year terms) and the 12 Health Systems Profile- Egypt Regional Health Systems Observatory- EMROAdvisory Council or Majlis al-Shura – which functions only in a consultative role (264 seats; 1 76 elected by popular vote, 88 appointed by the president; members serve sixyear terms; mid-term elections for half the members). People's Assembly election is in three phase voting, last held 19 October, 29 October, 8 November 2000 (next to be held October-November 2005); Advisory Council – last held May-June 2004. The Shoura Council was established constitutionally in 1980. The Shoura Council is mainly a â€Å"think-tank†to advise the Government on national policies.A committee of the Shoura Council on Health, Population and Environment examines issues relevant to these areas prior to their discussion in the Shoura Council’s plenary sessions. Although it does not have a direct legislative role, laws impacting significantly on broad government policy are required to be discussed by the Shoura Council before being passed to the People’s Assembly Laws, before going to the plenary sessions of Parliament, are referred for preliminary study to the relevant c ommittees. These specific committees are currently 22 in number; an example is the Committee for Health and Environment.This committee, consisting solely of Members of Parliament, often invites experts to its meetings for the purpose of obtaining a more comprehensive view of topics under study. The committee influences health policy changes planned for the future 13 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO 3 H EALTH STATUS AND DEMOGRAPHICS 3. 1 Health Status Indicators Table 3. 1 Health Status Indicators 1990-2005 Indicators 1990 1995 2000 2004 2005 65. 3 (92) 66. 9 (98) 67. 1 (01) 70. 1 (02) – – – – – – 63 66 24. 5 22. 4 20. 5 – 3. 9 (97) 33. 8 28. 6 26. 2 174 (92) 96 (98) 84 (01) 68 (02) 3 – – – – – 26 29. 8 28. 7 NA 17. 6 Prevalence of wasting 3. 4 4. 6 Source: NICHP Report, Ministry of Health and Population,2005. 2. 5 NA 3. 9 Life Expectancy at Birth HALE Infant Mor tality Rate Probability of dying before 5th birthday/1000 Maternal Mortality ratio Percent of Normal birth weight babies Prevalence of stunting Egypt Human Development Report,2004 Table 3-2 Indicators of Health Status by Gender and by urban rural 2006 Indicators Urban Rural Male Female Life expectancy at birth – – 69. 2 73. 6 HALE – – – – Infant Mortality Rate 27. 7 15. 3 – – Probability of dying before 5th birthday/1000 3. 9 20. 6 27. 6 24. 7 Maternal Mortality Ratio – – – – Percent of Normal Birth Weight Babies – – – – – – – Prevalence of stunning/wasting Source: NICHP Report, Ministry of Health and Population,2005. WHO Web Site,August 2005 14 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Table 3-3 Top 10 causes of Mortality Mortality Y2005 Rank Intra-cerebral hemorrhage 21,473 Essential (primary) hypertension 20,354 Fibrosi s and cirrhosis of liver 18,434 Hepatic failure, not elsewhere classified 11,353 Atherosclerosis 10,800 Arterial embolism and thrombosis 8,233 Elevated blood glucose level ,000 Acute myocardial infarction 6,645 Cerebral infarction 6,334 Others 320,011 Total 431,637 Source: NICHP Report, Ministry of Health and Population, 2005. The Burden of Disease and Injury in Egypt (Mortality and Morbidity). 2004. 3. 2 Demography Demographic patterns and trends Total population of Arab Republic of Egypt is 77,505,756 (July 2005 est. ). The age distribution is 0-14 years presents 33% (male 13,106,043/female 12,483,899), 15-64 years presents 62. 6% (male 24,531,266/female 23,972,216), 65 years and over presents 4. 4% (male 1,457,097/ female 1,955,235) (2005 est. ).Net migration rate is -0. 22 migrant(s)/1,000 population (2005 est. ). Sex ratio: at birth 1. 05 male(s)/female, under 15 years it is 1. 05 male(s)/ female, 15-64 years it is 1. 02 male(s)/female, 65 years and over it is 0. 74 male(s)/fem ale, for the total population it is 1. 02 male(s)/female (2005 est. ) The median age is 23. 68 years, 23. 31 years for males and 24. 05 years for females (2005 est. ). Eastern Hamitic stock (Egyptians and Bedouins) presents 99%, Greek, Nubian, Armenian, other European (primarily Italian and French) presents 1%. Muslim (mostly Sunni) 94%, Coptic Christian and other 6%.Arabic is the official language, English and French are widely understood by educated classes. 57. 7% of the population (age 15 and over) can read and write. Male presents 68. 3% and female presents female: 46. 9% (2003 est. ). 15 Health Systems Profile- Egypt Regional Health Systems Observatory- EMRO Table 3-4 Demographic Indicators Indicators 1990 1995 2000 2004 2005 – 27. 9 1997 27. 9 27. 0 (03) 25. 8 (05) – 6. 4 1997 6. 3 6. 4 (03) 6. 4 (05) 2. 4 (60. 86) 2. 08 (86-96) 2. 3 (96-02) 2. 0 (03) 19. 1 (05) 74. 7 1992 69. 7 1998 69. 9 (01) 69. 9 (02) – – 37. 8 1996 38. 8 (03) 37. 4 – 3. 90 1992
Sunday, January 5, 2020
The Supernatural In Macbeth Essay - 1944 Words
The Supernatural and its’ affect in the play Macbeth The supernatural has always fascinated and continues to intrigue mankind. In many of Shakespeare’s plays, he uses the supernatural to strengthen a particular scene or to influence the impression the audience has about someone or something. This was not strange or uncommon in Shakespeare’s time. In fact, during the 1500s, many people still believed in witches and witchcraft. Even in today’s society, with such advanced science and technology, many people are still influenced, if not dictated by the supernatural. For example, religious people have the belief that their saviour, Jesus Christ was a man of many miracles; one of which was he turned water into wine. Despite the fact that it†¦show more content†¦The first witch had previously sworn to take revenge on a sailor. The second witch then promises to help the first witch by using the wind. This scene demonstrates how weather is used to augment the witches’ powers; thus increasing the fear we have for the witches. The morning of Duncan’s murder, Lennox feels that something horrible occurred the night before. Lennox says, â€Å"The night has been unruly: where we lay, our chimneys were blown down, and as they say†¦of dire combustion and confused events†(2, iii, 58-62). This connects the weather and how it reacts to the untimely and brutal murder of King Duncan. Lennox describes that the night was chaotic, the chimneys made a lot of noise, and that the Earth was shaking so badly it could be described as if it was having a fever. These events prove that weather is significant in the play as it alters the viewers’ or readers’ perception. Another important factor that sets a dark atmosphere is how the animals react to the events of the play. From cats to dogs, animals have always been portrayed with the supernatural. In Egyptian time, cats were perceived as god-like creatures and treated as such. In Macbeth, animals played a different, but crucial role. In Act 2, scene 2, Lady Macbeth states that she had heard an owl shrieked, at the same time Macbeth was killing Duncan. It is evident that there is a relationshipShow MoreRelatedThe Supernatural in Macbeth874 Words  | 4 PagesThe Supernatural in Macbeth The supernatural contributes significantly to the story in the thrilling play Macbeth, written by Shakespeare. The paranormal signs and powers show considerable overlap with insanity in the case of several characters throughout the play. The superhuman agents that appear or contacted in the play are used for evil purposes in almost all the cases, and are predominantly resulting in the death of a human being. First of all, the three witches are using supernatural powersRead MoreThe Supernatural In Macbeth1858 Words  | 8 Pages In the play Macbeth by WIlliam Shakespeare, the supernatural is an ever present force, seen in the witches, the ghost of banquo, and maybe some other places. The way Shakespeare portrays the supernatural, and especially the witches, add a great deal s to the play, and also contribute in key ways to the themes, structure, tone. Mood, and literary devices in ways that are designed to affect the audience of the play. The most important contribution in my opinion, was that they made the play scaryRead MoreTheme Of Supernatural In Macbeth773 Words  | 4 PagesShakespeares Macbeth, the supernatural and the role it plays in motivating characters is present throughout the duration of the play. The supernatural causes conflict in the play and the prophecies from the witches in act one is the inciting action. 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The use of the witches, the visions, the ghost and the apparition is key to making the idea of the plot work and it adds the elements of thrill and suspense to the audience. Reading through each act and scene of the play, it is noticed that the supernatural is in reality a primary concept of the play’s plot. The use of the supernatural emerges at the start of the play, with three witches predicting the destiny of Macbeth. The audience now has an idea asRead MoreMacbeth - Supernatural Theme809 Words  | 4 PagesThe presence of supernatural forces in William Shakespeare s, Macbeth, provides for much of the play s dramatic tension and the mounting suspense. Several supernatural apparitions throughout the play profoundly affect Macbeth and the evil forces eventually claim Macbeth and destroy his morals. Macbeth s ambition was driven by the prophecies of the three witches and unlike Banquo, he was willing to do anything to assure that they actually transpire. Macbeth is horrified at the notion of killingRead More The Supernatural in Macbeth Essay3374 Words  | 14 PagesThe Supernatural in Macbeth   More than a few elements of the supernatural can be discovered within the action and dialogue of Shakespeares plays. However, the extent and nature of those elements differs to a large degree. There are traces of it to be found in Henry V, Pardon, gentles all,/The flat unraised spirit that hath dard...to bring forth/So great and object (Lucy 1).  There are also elements of it apparent in Winters Tale, What I did not well I meant well (Lucy Read MoreThe Supernatural in Macbeth Essay1031 Words  | 5 PagesFrom witches to apparitions, supernatural elements are the constituents of the play, Macbeth. The supernatural occurrences served as role as a manifestation of evil temptations that seduced Macbeth into murdering, even his own comrades. Macbeth’s first meet with the supernatural was the ignition of his ambition to kill for his own success; the second encounter of the supernatural allowed his sanity and judgment to wander off to a murdererâ €™s mind with the basis of his before gained ambition. Supernatural’sRead MoreMacbeth : Influence Of The Supernatural2958 Words  | 12 PagesMacbeth Essay- Influence of the Supernatural â€Å"The supernatural is the natural not yet understood.†(Elbert Hubbard) Within the realm of Williams Shakespeare’s â€Å"Macbeth†, supernatural elements play a prevalent role throughout the telling of the tragedy. Created in a time period in which fear of the unknown ran high and belief in the supernatural was rampant, the incorporation of mystical components resulted in a compelling story for the people of the Elizabethan era. Moving forward into the modernRead MoreOccult and Supernatural Elements in Macbeth1402 Words  | 6 PagesAlthough Macbeth is not classed as being a supernatural play or a play of the occult, there are some elements in the play that Shakespeare uses to effect. It is necessary however, to define what is meant by the terms ‘occult’ and ‘supernatural’: the term ‘occult’ is defined as being ‘supernatural beliefs, practises or phenomenon’ and the term ‘supernatural’ is de fined as being ‘attributed to some force beyond scientific understanding or the laws of nature’; both these terms can be associated with
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