IV. DETERMINANTS OF HEALTH AND NUTRITION STATUS IN EGYPT

Section One: Dietary Practices
Supply of Food: (Household Food Security)
Government Policies in Egyptian Agriculture
Agricultural Policy Instruments
Investment Allocation Pattern in Agriculture
Impact of the Agricultural Policy and Investment Allocation Pattern on the Nutrition Status of Egyptians
The Contribution of Selected Food Groups to Dietary Energy Supply "DES"
Egyptian Rationing and Food Subsidy
Agricultural Policy Reforms 1986-1988
Major Agricultural Policy Reform Objectives in the Period 1990-1993
Expected Impact of Agricultural Policy Reform on Agricultural Production
Demand on Food and Health Services
Incomes
Income Effects of the Reform in the Agricultural Policy
Income Effects for Urban Households
Prices of Food and the Egyptian Ration System and Subsidies
Food Consumption and Intake
Nutrient Intake and Variation with Different Factors
Infection in Egypt
Health System in Egypt
Health Policies and Priorities in the Seventies and Eighties
Effects of the Changes in the Health Policies Over the Seventies and Eighties on the Health Sector
Main Health Interventions
Impact on Cases of Severe Dehydration Among Children
Impact on Infant and 1-4 Year Child Mortality Due to Diarrhea
Child Survival Project (CSP)
Family Health History (Caring Capacity)
Caring Capacity
Caring Capacity Within the Society
Environment
Infant and Child Feeding
Family Planning Policies and Child Spacing
Nutritional and Health Interventions Affecting Family Health

Section One: Dietary Practices

(...)

Supply of Food: (Household Food Security)

(...)

Government Policies in Egyptian Agriculture

(...)

Agricultural Policy Instruments

(...) consistently taxed. Wheat producers were protected in the early 1970s when wheat prices were particularly low. Maize and sugarcane production for which no price control was in effect during the period, has been taxed in most years as result of import policy.

Investment Allocation Pattern in Agriculture

The sectoral development in Table 12 App. and Figure 12 shows that economic growth in Egypt is distributed in an uneven pace among the different sectors. Since 1952 the agricultural sector was a slow growing sector with average growth rates of about 2% over the first half of the seventies after 3.5% on average in the period 1955/56-60/61. The share of investment allocated to agriculture declined sharply in the second half of the sixties and in the seventies to reach about 8% in 1973, after a sharp increase in it in the first half of the sixties (20%), while building the Aswan high Dam. The relatively low investment share allotted to the agriculture sector in Egypt shown in Table 12 App., reflects the Development from Above Strategy mentioned in Part two of this report.

Impact of the Agricultural Policy and Investment Allocation Pattern on the Nutrition Status of Egyptians

To investigate the impact of the agricultural policies over the 1970s and 1980s on the nutrition status firstly we have to discuss their impact on the production of foodstuffs and secondly their effect on food self sufficiency and food supply. Production and supply of food are direct determinants of the nutrition status beside other factors.

Impact of the Agricultural Policy on the Production Trends in the Agricultural Sector

Total cultivated area in Egypt has been increasing slowly during the last two decades from 5.8 million feddan in 1971/72 to an estimated area of 6.09 million feddan in 1987/88. With the high rate of growth of Egyptian population, per capita share in crop area declined from 0,36 in 1966 to 0,22 in 1986. The most significant changes have been the decline in the crop areas of the fixed priced crops such as cotton, maize, rice and sugarcane in 1988, if compared with the period 1974-80. The drop in output was due to yield and area decreases and reflected rapid rise in costs of production in relation to permanent prices. Meanwhile an upsurge in the crop areas of free priced crops like vegetables, fruits and berseem occurred over the same period. Overall agricultural growth in 1980-86 declined to 1.9% in 1980-86 after 2.5% in 1965-80 and was lower than the estimated population growth at 2.8 percent (Fletcher, 1989). From being a net exporter of agricultural products in the early 1970, the country now faces an annual net deficit in its agricultural trade balance. Agricultural exports, which were the major foreign exchange earnings sector before 1974 was placed by the oil in 1974 and declined from 40% in 1974-79 to 20% in 1980-86 (Figure 16). Moreover, agricultural imports, (mainly wheat and flour) at current prices have increased threefold from 1974-79 to 1980-86, consequently the agricultural trade balance, which showed a surplus until the early seventies, indicated a deficit of L.E 94.3 million over the period 1974-79 and L.E 355 million during the second and third periods (Table 19). With growing income per capita, increasing income elasticities and rising population size, growing imbalances occur between domestic supply and demand for food and agricultural products. The structure of the Egyptian economy was thus characterized by the large but declining share of agricultural from 18.7% of GDP in 1967-73 to 14.3% in 1980-86. Moreover the agricultural output has stagnated since 1980/81.

Furthermore, the Egyptian government's exchange rate and trade policies that encouraged imports that is wheat led to a relative decline in agricultural exports (Figure 16). This decline was also a result of a significant drop in the country's self sufficiency ratios in food (Dethier, 1987). Moreover taxing agriculture with price and subsidy instruments created black markets for inputs, diverting subsidized inputs to profitable crops.

Table (19)

AGRICULTURE AND TRADE SECTOR SHARES MILLIONS L.E

PERIOD	1967-73	1974-79	1980-86
AGRICULTURE SHARE OF GDP	18.7	18.4	14.3
TOTAL IMPORTS	377.4	1900.0	6267.7
AGRICULTURE IMPORTS	86.8	388.5	1113.5
AGRICULTURE SHARE OF TOTAL IMPORTS	23.0	20.4	17.7
TOTAL EXPORTS	318.2	729.0	2296.5
AGRICULTURE EXPORTS	211.3	294.2	455.0
AGRICULTURE SHARE OF TOTAL EXPORTS	66.4	40.4	19.8
TOTAL TRADE DEFICIT	-59.2	-117.1	-3971.2
AGRICULTURE TRADE DEFICIT	+124.5	-94.3	-355.0

SOURCES: ARAB REPUBLIC OF EGYPT NATIONAL PLANNING INSTITUTE. RESEARCH PAPER NO. 45, CAIRO: NPI, 1989. P50

Figure 16. STRUCTURE OF EXPORTS - Egypt

in percentages

The Impact of the Trends in the Agricultural Production on Food Self Sufficiency and Food Supply

One should distinguish in Egypt between food self sufficiency and supply of food in Egypt.

With respect to food self sufficiency, the end result of the production trends in crop and yields area was a serious deterioration in the country's ability to feed itself. Self sufficiency ratio for important food items for 1987 in Table 20 shows that production was less than a quarter of consumption for wheat and less than a third for vegetable oil, lentils and less than two thirds for maize and chicken. 1989/90 figures show some improvement for wheat, maize and lentils and a deterioration for the rest.

Table (20)

Self-sufficiency Ratios for Key foods, 1987.

	Domestic Production	Imports ('000 tons)	Consumption ('000 tons)	Production as % of consumption
Wheat	1.929	6.857	8.786	22
Maize	3.900	2.028	5.928	66
Rice	1.330	-	1.330	100
Beans	282	-	282	100
Lentils	14	15	29	48
Sugar
Veg Oil	161	474	635	34
Chicken	110	65	175	63
Beef	396	131	527	75

Source: The Economist Intelligence unit, Egypt country profile 1988-89. London, 1988 pp 21-22.

Furthermore, food aid's share in total wheat imports has increased from 0% in 1970 to 49% in 1978. But by 1988 this share declined to 21%. The importance of food aid in food self sufficiency is revealed in Table 20. Imports accounted for more than three fourth of wheat, two thirds of vegetable oil and almost one half of sugar consumed. The one third of maize that was imported was for animal feed. In addition meat imports (beef and chicken) were also important.

Moreover as far as food supply is concerned, the food availability in Egypt is comparable to levels of developed countries and far exceeds the average availability for developing countries (Average percaput food supply - 6/Day: Developed: 3050, Developing: 2150 and Egypt 3196) (Galal and Amine, 1984). Figure 17 shows calorie supply per capita in Egypt during the period 1961-1988. Food availability in Egypt increased steadily from 2402 over the period 1969-71 to 3196 in 1986-88.

Figure 17. Calorie Supply Per Capita - Egypt (1961-1988)

Source: FAO Food Production Yearbook, 1989

Table (21)

TREND OF DIETARY PATTERN IN EGYPT OVER 20 YEARS PERIOD

ITEMS Related to Diseases of Affluence		Available
		Per Individual	Per Day
		1965	1985
Selected Food Items
	Meat (GM)	31.8	49.9
	Fish (GM)	12.0	14.8
	Milk (GM)	87.1	128.7
	Sugar (GM)	46.6	101.4
Selected Nutrients
	Energy (KCAL)	2400	3313
	Protein (GM)	64.6	81.1
	% Derived from Animal Food Sources	14.0	18.0
	Animal Fat (GM)	5.5	10.1

Developed from: Egypt food balance sheets (Ministry of Agriculture, 1989)

Table 21 shows that meat and milk have increased almost by 50% while sugar has increased more than twice. Animal fat almost doubled. This total energy has almost increased by 50%. There is also an increase in the animal protein and animal fat. Food availability was indicated quantitatively by dietary energy supply (DES) and qualitatively by protein and fat at plant and animal origins.

DES presented as percaput total calories per day ranged from 3660 Kcal during 1969 to 3501 Kcal in 1986 (Table 19 App.). There was a rise of 231 Kcal percaput per day from 1969-1970. The level of DES continued almost at the same level till 1974 when there was a rise of 252 Kcal during 1975 and a further rise in 1981 and 1985 and a drop in 1986. Figures of total protein almost followed DES as a big proportion (> 50%) is supplied by bread. Percaput protein supply per day ranged from 74.6 gm in 1969 to 106.7 gm in 1981 and slightly dropped to 90.6 gm in 1986. Supply of animal protein followed a different route. It remained almost steady from 1969 to 1977 ranging from 10.6 to 12.5 gm/day. There was a slight rise in 1978, a drop in 1979 then a rise of 25% in 1980 which continued with minimum fluctuations till 1986 to reach 14 gm/caput/day. Animal protein supply is governed by subsidized meat, poultry, fish and eggs distributed through government cooperative stores. Total fat remained stable for 5 years from 1969-1973 around 48 gm/caput/day with increase of 6 gm in 1974 then a sharp rise of 8 gm/day in 1975 to reach 61.3 gm/caput per day. It remained at that level till 1985 when there was a sharp rise which continued to 1986. Total fat increased from 48.8 gm/caput/day in 1969 to 78.2 gm in 1986 with more than 60% rise. However, animal fat increased from 12.3 gm/caput/day to 18.7 gm in the same period with a rise less than 155 which attributes the rise mainly to vegetable oil imports. To conclude:

- There is a general increasing trend in the food availability in Egypt in the seventies after 1973, if compared with the eighties. Since 1981 ups and downs fluctuations occurred in the DES, animal and plant protein as well as animal and plant fat.

- This might be explained by the significant increase in food imports over the seventies as a result of the increase in foreign exchange over the period. The fluctuations in the food availability in Egypt over the eighties reflect the deterioration in food self sufficiency and a tight resource situation that led to a decline in the rate of growth of food imports.

The Contribution of Selected Food Groups to Dietary Energy Supply "DES"

It is important to examine the impact of the changes in food supply on the DES. Cereals are the main contributors to DES in Egypt as evident from the series of Food Balance Sheets from 1969-1986 (Table 22). Cereals supply increased from 61.6% to 79.5% of DES during this period. The highest value was in 1978 (79.5%), the lowest was in 1986 (61.6%). Cereals in Egypt are mainly wheat, which is the main staple, rice and com. Cereals also are the main contributors to protein supply in Egypt.

Table (22)

Contribution of different food groups to Dietary Energy Supply Trends in 18 years Period "FBS".

Contributing food groups	THE YEAR
	1969	1970	1971	1972	1973	1974	1975	1976	1977	1978	1979	1980	1981	1982	1983	1984	1985	1986
Vegetables products:
Cereals	64.5	72.2	69.9	68.4	69.9	71.8	71	69.2	70	79.5	69.8	70	70.8	68.9	69.2	72.7	70.9	61.6
Legumes	5.4	4.5	4.3	5.3	5	4.1	4.1	4.4	4.1	4	3.7	3.7	3.6	3.7	3.4	3.5	3.4	3.6
Sugar and Sweets	6.7	6.6	7.5	8.1	7.7	6.7	6.5	7.3	7.2	9.3	7.5	7.6	7.5	7.5	7.8	7.4	6.6	11.6
Vegetables	2.9	2.4	2.7	2.4	2.3	2.2	2.3	2.3	2.3	2.6	2.5	2.7	2.2	2.2	2.4	2.3	2.4	2.8
Fruits	3.2	2.6	3	3.2	3.1	3	2.8	2.9	2.9	2.9	2.9	3.1	2.7	3.0	3.1	3.0	2.7	3.7
Oil	6.7	5.5	6	6.6	6	6.5	8	7.5	7.6	9.3	7.3	5.9	6.7	7.3	7.2	5.2	8.5	10.9
Animal products:
Heat	1.4	1.3	1.4	1.3	1.2	1.1	1.1	1.2	1.2	1.3	1.1	1.2	1.3	1.3	1.4	1.3	1.5	1.4
Poultry	0.4	0.3	0.4	0.4	0.4	0.4	0.3	0.3	0.4	0.4	0.4	0.5	0.5	0.3	0.5	0.4	0.5	0.5
Fish	0.2	0.1	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.3	0.2	0.3	0.3	0.3	0.3	0.6	0.3.	0.3
Eggs	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.3	0.3	0.3	0.4	0.5
MiIk and milk products	4.6	4.2	4.3	4.2	4.1	3.8	3.6	4.4	4	5	4.4	4.8	4.4	4.1	4.5	3.3	2.9	3
Fats	4.2	3.4	3.9	3.8	3.7	3.4	3.3	3.8	3.7	4.2	3.7	4.1	3.8	3.8	4.0	3.6	3.3	3.5
% contribution of total animal products to "DES"	11.0	9.5	10.4	10.1	9.8	9.1	8.7	10.1	9.7	11.4	10.0	11.1	10.5	10.1	11.0	9.5	8.9	9.2

Developed from: Serial Food Balance Sheets of Egypt (Ministry of Agriculture, 1991).

Sugar and sweets contribution to DES was in the range of 6-8% during the period 1969-1985 with a sharp rise in 1986 to reach 11.6%, which means almost 80% increase above the value at 1969. Since DES is increasing during this period so absolute values of sugar and sweets are also increasing with a jump in 1986. Vegetables and fruits are minor contributors with a rise in fruit supply in 1986.

Vegetable oil supplied around 6-7% of DES during this period with a rise in 1978 and 1986. From the animal products meat, poultry, fish and eggs manifested almost steady supply during this period. However, milk and its products together with animal fat had a drop in supply which started 1984 and continued. The percentage contribution of total animal products to DES ranged from 8.9% to 11.4% with minor fluctuations and a drop since 1984.

Thus, one may conclude, that imports are highly contributing to the Dietary Energy Supply in Egypt, which is depending mainly on cereals. This may be interpreted as an indirect impact of the agricultural policy in Egypt.

The rise in fruit supply in DES in 1986 may be associated with the upsurge in the crop areas of free priced crops like fruits.

Egyptian Rationing and Food Subsidy

Objectives of the Rationing and Food Subsidy Program

It is difficult to discuss food supply in Egypt without examining the trend in the Egyptian ration and food subsidy. This program is related to the goal of food security and equity in income distribution, which was emphasized since the sixties. The subsidy and ration system has also a direct nutritional concern. For example, the stress on animal protein may partly reflect the viewpoint on nutrition.

Other objectives of the Egyptian rationing/subsidy program are:

1. To isolate the domestic economy from international shocks and short-term domestic shortfalls. Price stability for basic food commodities was of major concern to Egyptian government policy makers.

2. The subsidy system also is related to the goal of food security. Egypt is facing a widening food gap between demand and domestic supply due to the increase in the rate of growth of population and real per capita income. Aggregate food self sufficiency were declining since 1980s for wheat, rice, coarse grains, sugar, cooking oil, and meat, including poultry.

Principal Commodities Subsidized

The food subsidy system in Egypt is one of the most extensive in the world. In 1989 approximately 93% of the population receives some form of ration card, with the major portion of the people receiving the full ration (green card: 47,085,001) and 1,416,013 receiving the partial subsidy (red card) (Kennedy, E., 1989). By the early 1980s, three types of products were subsidized or rationed (Alderman et al., 1982).

Wheat flour and bread were sold at a fixed price, uniform throughout the country in unlimited quantities. Sugar, tea, cooking oil, rice, beans and lentils were sold at subsidized prices and were rationed in fixed monthly quotas, which vary according to governorates and to the rural or urban location of household. Monthly quotas were less assured for beans and lentils. Additional quantities were available at higher prices in cooperatives and government stores. Finally meat poultry and fish (frozen) were also subsidized, but in limited quantities. Some subsidized items were used as inputs for the food processing sector flour (to bakeries), oil (e.g. for margarine), and imported yellow maize (for poultry feed and other industrial processes).

Types of Subsidies

There are many types of subsidies in Egypt; direct and indirect; explicit and implicit; producer and consumer subsidies et. Direct subsidies refer to those subsidies for which specific allocations are made in the budget. These subsidies are awarded to certain public sector organizations in order to enable them to sell certain goods or services to consumers or producers at price usually lower than procurement prices (Carr, D., 1990).

Economic Costs of Food Subsidy

The overall magnitude of the subsidy burden is presented in Table 23. After rising steeply from L.E. 108 million in 1973 to 621 million in 1975 to a peak of L.E. 2909 million in 1985/86, the explicit budgetary outlays for subsidies declined. But even in 1988/89, at L.E. 1813 million they still constituted about 11.1% of total government expenditure. This is due to two factors: The reduction in their absolute magnitude as well as the expansion in the budgetary outlays.

Food subsidies during the 1970s represented an extremely sizable share of various subsidy types. Food subsidies relative to government expenditure decreased from about 97% in 1973 to 66% in 1980/81, to almost 47% in 1989 and from 98% to total subsidy in 1973 to 5% in 1988.

Funds allocated for wheat and flour subsidies are the most significant among food subsidies. It was at its lowest level (LE 79 million) in 1973, and it did attain its maximum exhibiting a downward trend since 1985, while attaining a level of L.E. 199 million in 1989. Table (20 App.) shows the allotments for major subsidized commodities in Egypt.

It is clear that funds allocated for sugar and edible oil have increased, and at the same time wheat and flour subsidies declined.

Example of implicitly subsidized goods include petroleum products, electricity, raw cotton, etc. The importation of subsidized goods using an exchange rate that is below open market rate is another example of implicit subsidization.

In 1986/87 the value to Egyptian consumers of all implicit subsidies provided by the government of Egypt by its not using the market exchange rate for the imports of wheat, flour, vegetable oil, or economic process for electricity, fuels, cotton, lint, and public sector industrial commodities was about L.E 8.5 billion, or 18 percent of GDP. The implicit subsidy burden was estimated to have risen to L.E 13.5 billion by FY 1988/89 (Carr, D., 1990).

Table (23)

Total, Food and Wheat Subsidies for the period 1973-1988/89 (L.E Millions)

Year	Govern Expendit	Total Subsidy		Food Subsidy		Wheat and Flour subsidy
		LE million	% of Gov. Ex	LE million	% of Tot. sub	LE million	% of Tot. sub.	% of Food sub.
1973	1177	108	9	105	98	79	73	74
1974	1432	419	29	317	75	221	53	69
1975	2297	621	27	320	51	162	26	50
1976	2526	427	17	297	69	178	41	60
1977	2673	464	17	310	66	149	31	48
1980/81	5478	2572	31	1690	66	901	35	53
1981/82	8149	2909	22	1779	61	807	28	45
1982/83	8437	2054	16	1337	65	758	37	57
1983/84	9331	1986	13	1209	61	862	43	71
1984/85	10752	2007	10	1121	56	615	31	55
1985/86	11522	2909	17	1928	66	449	15	23
1986/87	10448	1746	10	1034	59	390	22	38
1987/88	13661	1650	6	837	51	236	14	28
1988/89	16283	1813	5	857	47	199	11	23

Sources:

1. El-Kholei "Objectives and Implications of Egyptian Food policies" Table (9, 10)
2. IFPRI Report 34 Table (1)

Agricultural Policy Reforms 1986-1988

The reform in the agricultural sector in 1986 is one of the main programs that will indirectly influence the nutrition status of Egypt.

The long-term goals set for these reforms were:

- remove government farm price controls;

- remove government crop area controls;

- remove government crop procurement quotas;

- remove government constraints on private sector processing and marketing of farm products and inputs;

- eliminate subsidies in farm inputs.

By late 1988, an ambitious program of agricultural policy reform was in process. Only cotton, sugarcane and rice remained under price, production, and marketing controls and steps were implemented to reduce input subsidies.

Major Agricultural Policy Reform Objectives in the Period 1990-1993

Agricultural policy reform objectives for the period (1990-1993) are:

1. to raise the procurement price of cotton to two thirds of its export value by 1992;

2. eliminate one half of cotton pest control subsidy by 1992;

3. eliminate compulsory, low-price delivery quotas of rice by 1992;

4. eliminate restrictions on private milling, transport and marketing of rice;

5. eliminate PBDAC exchange rate subsidy;

6. eliminate budget subsidies for all nitrogen and phosphate by (1993);

7. eliminate livestock feed subsidies by 1992;

8. divest PBDAC responsibilities for importing and retail marketing of corn and other animal feed;

9. limit farm credit subsidies;

10. encourage privatization in seed marketing system;

11. deregulation for cooperatives (Ministry of Agriculture, ARE, 1991).

Expected Impact of Agricultural Policy Reform on Agricultural Production

Expected impact of agricultural policy reform should be studied on both aspects: production, as well as incomes and consumption. As long as this part of the study is mainly concerned with the production and supply side we will discuss the effects on incomes prices and consumption in the following section.

McCarl, Quance, and Khedr (1989) presented a model of the Egyptian Agricultural Sector (EASM) to estimate the impact of a total decontrol of the Egyptian agricultural sector. The model shows that under free market conditions cotton begins to regain its dominance in Egyptian agriculture with a 17% increase in long staple cotton area and a 369% increase in cotton exports to 443,000 metric tons compared to 120,000 metric tons under the base case scenario.

The long season berseem area decreased to 9% relative to the base case. Rice production increases almost 17% in response to higher prices, while wheat production decreases almost 6% due to lower prices. Both citrus and vegetable production decline moderately as they become less profitable relative to higher priced cotton and rice.

With the increase in cotton exports, the agricultural trade balance shifts from a deficit of 727 million LE in 1986 base case to a surplus of 52099 million LE under the free market scenario.

The Egyptian farmers would not produce sugarcane, horse beans and lentils under the free market scenario.

Finally, under the free market the total current value of farm output would be higher. Producers surplus
increases very large (46%) at the expense of consumers surplus compared to the base case. This, indirectly, will affect the demand on food, as will be indicated in the coming section.

Demand on Food and Health Services

As known in economic literature, the determinants of demand on food and health services are: incomes, prices of food, preferences of the individuals and the prices of complementary and supplementary goods and services. In this respect several policies and programs in Egypt were relevant, such as the growth oriented policies, sectoral development policies, employment policies, wage trends, the pricing policy as well as the ration and subsidy system. No doubt that the macro economic policy reform is one of the most important policies affecting directly the trends in incomes, wages and prices and indirectly the demand on food.

Incomes

Incomes are highly significant in explaining observed family calorie and protein deficits. In the study of Alderman and Braun 1984 high income elasticities for calories in Egypt were indicated (about 0.2 overall and about 0.4 for the poorest quartile). Moreover, rural urban differences exist. An increase of LE 5 in monthly per capita income will reduce the probability of a calorie deficit by 0.01 (mean = 0.17) in urban areas, whereas an increase of LE 1,5 would achieve the same reduction in rural areas. Income elasticity estimates for the different population groups are estimated in Tables 21 and 22 App. The demand for most food commodities are expected to increase with income. Income elasticities were found highest for fish, meat, chicken, fish, eggs, fruit and milk. Income elasticity is negative in urban areas for balady flour and bread and virtually zero in rural areas for balady bread, indicating that balady bread and flour are inferior goods (Alderman and Braun, 1984).

Due to data limitations we will discuss only the trends in real wages and the incidence of poverty and income distribution in Egypt Two main policies were found relevant in this respect, overall growth policies and employment policies.

Overall Growth Policies

Overall growth policies may influence the health and nutrition status of the population implicitly by determining: the level of GDP growth rates and GDP per capita growth rates, which will affect directly and indirectly the trends in wages and income levels: basic determinants of the demand on food. In addition, income distribution and poverty incidence are relevant subjects.

Meanwhile, it is difficult to study the overall growth rates in Egypt over the 1970s and 1980s, if we do not divide this period into four periods, as follows: 1970/1973, 1974-1980/81, 1981/82-1984/85 and 1985/86-1991/1992. Each period is characterized by different policies and socio-economic events. The period 1970-73 is usually included under the inter-war period 1967-1973 (Handousa, H., 1987). Annual growth rates of GDP were small in the years 1972 and 1973 (Table 24). The economy during the war period could not sustain the pace of high economic performance during the central planned period 1960-1965 (Table 12 App.). Meanwhile it is important to note that the rate of growth of per capita income dropped to less than 1% over the period 1966-73 with a negative rate in it in 1972. The share of gross investment in GDP declined sharply after 1965/66 from a ratio of 18.1% in 1965/66 to 13% in 1970/71 and 13.1% in 1973. Sectoral GDP growth rates witnessed a remarkable decline. Over the period 1974-1980/81. Egypt experienced a period of unexpected growth. The annual growth rate in Egypt was 9% on average. The reasons of growth was not an improved domestic productive efficiency but the very rapid growth of external resources from oil, Suez Canal tourism revenues and remittances (Figure 13). This significant overall growth was reflected on the investment ratio to GDP which rose from 23% in 1974 to 30% in 1980/81. The period after 1981/82 in general contrasts sharply with the period 1974-81/82. Egypt's economic situation began to deteriorate in 1980/81 reflecting a sharp decrease in the growth of external resources. However, a relatively high overall growth rate of 5% to 6% on average could be achieved through expansionary monetary and financial policies. The period 1986/87 till present may be distinguished as a separate era in which the Egyptian economy witnessed major changes in the macro economic policies. The Egyptian government could not maintain the high growth rates through expansionary economic policies, which resulted in increasing balance of payments deficits and increasing debt service obligations as a result of foreign borrowing. This was reflected on the declining trend in GDP and investment growth rates, government consumption and import growth rates. The Egyptian government, since 1986, undertook different measures to reduce the budget deficit and initiated a reform program, which was discussed in part II of this report (Nassar, H., 1990).

Nevertheless, overall growth rates affected the trends in per capita income in real terms as well as the incidence of poverty and the trends in real wages.

Per capita income

Per capita income grew by 7% a year in real terms between 1973 and 1982. However the decrease in the rate of growth of GDP to 2,5% in 1986/87 with a rate of population increase between 2,5% and 2,8% led to a negative rate of growth in GDP since the mid eighties. As indicated in Figure 18 GNP per capita increased from $280 in 1976 to $ 720 in 1984 and then it decline to $610 in 1985. After a significant increase in it to $760 in 1986 and on going declining trends occurred in it in 1987 and 1988.

Meanwhile, in spite of the overall growth over the seventies incidence of poverty in Egypt was not eliminated. In spite of methodological and data limitations in the estimation of poverty line, Table 25 can be used as an approximate measure of the overall incidence of poverty. In 1982 poor households represented between 22 and 30 of the total number of households (World Bank, Poverty Alleviation, 1990). Depending on Korayam K's estimate, proportion of poor households in 1984 has reached 33,7% and 34% in rural and urban areas, respectively. It is noteworthy to mention that in accordance to this estimate the poverty line refers to that level of income that is sufficient to ensure a minimum nutritional and basic consumption level of the individual at the official prices. Thus, the increase in the prices of food was clearly reflected on the rise in the proportion of poor households. Using market prices for food 51.1% of urban households and 47,3% of rural households were found under the poverty line (Korayam, K. 1987).

Table (24)

RATE OF ANNUAL INCREASE AND INDEX NUMBER OF EMPLOYMENT INVESTMENT AND PRODUCTION (IN FIXED PRICES OF 1960)

ECONOMIC SECTORS YEAR		TOTAL	AGRICULTURE & IRRIGATION		MANUFACTURING & MINING		TOTAL PRODUCTIVE SECTOR		SERVICE SECTORS
			R(%)	X	R(%)	X	R(%)	X	R(%)	X
59/60-65/66 BASE YEAR 59/60	L	126,6	3	119,5	5,8	139,9	3,8	125,3	4	128,8
	I		18,9	249,1	12,6	182,4	20,3	263,4	6,7	137,6
	P		3,7	-	8,5	163,3	7,4	150,3	6,7	148,6
66/67-73 BASE YEAR 66/67	L	114,9	1	106,4	4,8	132,6	1,7	110,6	2,3	121,1
	I		(-13,5)	60,1	2,7	110,2	-2,4	83,9	10,9	168,6
	P		1,6	-	4,9	131	4,8	132,5	7,4	144,1
74-80/61 BASE YEAR 1974	L	122,7	-	99,9	3,4	122,4	1,8	111,6	3,5	141,5
	I		22	319,3	21,9	321,8	24,6	366,3	38,7	354,7
	P		3	-	7,9	158,8	7,5	235,9	15,6	218,4
82/83-86/87 IN FIXED PRICES OF 81/82 & BASE YEAR 82/83	L	114,1					2,2	111,1	3,6	118,1
	I	120	16,1	180,6	2,0	107,5	3,6	115	4,5	125
	P	137,8	2,5	118,1	8,5	150,4	6,5	136,7	13,9	139,3
87/88-91/99 IN FIXED PRICES OF 86/88 & BASE YEAR 87/88	L
	I
	P	123,9	3,7	115,8	7	132,9	5,7	124,8	10,2	122,6

L: Labour, I: Investment, P: GDP

Calculated From:

Shura Council, Investment Policies
Second Five Year Plan for Economic & Social Development, May 1987

R: Rate of Growth (%)
X: Index Number.

Figure 18. GNP Per Capita (1976-1989)

Source: World Development Reports

Table (25)

Incidence of Poverty in Egypt

	Proportion of Poor Households (%)	Number of Poor Households (000)
1958/59
Rural	35	1161
Urban	30	597
1974/75
Rural	44	1833
Urban	34.5	1076
1981/82
Rural	24.2-29.7	1023-1240
Urban	22.5-30.4	756-1196
1984
Rural	33.7-47.2	1476.1-2067.4
Urban	34-51.1	1444.7-2171.2

SOURCE: World Bank, Poverty Alleviation and Adjustment in Egypt, Volume II, June, 6, 1990

KORAYAM, K. The Impact of Economic Adjustment Policies on the Vulnerable Families and Children in Egypt, A Report Prepared for The Third World Forum, Middle East Office and the United Nations Children's Fund (UNICEF) Egypt, 1987.

Data on income distribution

Data on income distribution show that the degree of inequality declined between 1974 and 1982 after a rise in it over the period 1964-1974. However it was found that a significant improvement occurred in it in the last decade, if compared with the fifties. Out of 44 developing countries, inequality was measured by the ratio between the share of income of the richest quartile over the share of the poorest quartile, Egypt's position was the 14^th (World Bank, Poverty Alleviation, 1990). In addition, the 1981/82 household budget survey shows that the richest 20% of households in rural and urban areas receive 44% on 40% respectively of total income, while the poorest 20% have only 6% and 7.5%, respectively.

The implications of poverty incidence distribution of incomes on health and nutrition

The implications of poverty incidence distribution of incomes on health and nutrition is a maldistribution in food Despite the fact that per capita daily calorie supply increased from 2,400 in 1973 to 3,300 in 1982, data on per capita consumption reveal that the consumption of the poorest 10% of the urban and rural population, represents 26% and 23% respectively, of the expenditures for the average urban and rural population while the richest 10% of urban and rural population consume about 255% and 227%, of the national average respectively (World Bank, Poverty Alleviation, 1990).

Meanwhile, while per capita calorie was 2843 and protein intake per capita was 96 grams in 1981, which represents 103% and 117% of energy and protein requirement, approximately 35% of the population consumes less than 2000 calories per capita. Inadequate consumption is worse in rural areas (38.5%) than in urban areas (33.1%) (Galal and Amine, 1984).

Wage trends reflect clearly the trends in the overall growth rates and employment policies in Egypt Since 1961 the Egyptian government maintained an administered wage system and a guaranteed employment scheme to graduates of secondary and post secondary schools as a consequence of the socialist transformation. The employment policies for military conscripts and the government employment guarantee policies made the public sector in Egypt the largest employer, accounting for nearly one third of the nation's total employment. These policies could also depress the rate of unemployment over the sixties and seventies to 2,7% in 1960, 1,15% in 1966. However with the tightness in the labour absorption capacity in the productive sector, this rate increased to 7.76% in 1976 and to 14,7% in 1986 (Nassar, H. 1989).

With respect to the trend in real wages, Table 23 App. and Figure 19 reveal differences in the rate of growth of real wages in the seventies, if compared with the eighties. The strength of the economy in the 1970s was reflected on the real wages. Real wages rose as the economy expanded, reaching a peak in the mid 1980. With the deterioration in the macro economic variables at the beginning of the eighties, they drifted downward afterwards (World Bank, 1990). The period 1973 till 1979 witnessed a construction and a general economic boom as previously mentioned resulting in an increase in the wages in the private construction and service sector. Meanwhile mechanization, migration and urbanization contributed to the increase in the real wages in the agricultural sector. Wages in the public manufacturing sector show a slight increase in 1979 if compared with 1973.

The deterioration in the macro economic variables after 1980s was reflected on the trends in wages in general. Since 1981, the economy began to weaken and the government could no longer afford the cost of over-staffing. A declining trend can be seen in the movement of real wages for the public service sector. Due to a rising wage bill and the struggle of the government to maintain full employment the wage bill was divided among a growing labour force. So real wages declined in the government and public manufacturing sector in the eighties if compared with the seventies. This increased the risk of labour market related poverty for workers in the government and the public enterprises.

The private sector in the agriculture, construction manufacturing service sector and the public construction sector showed an increase in the real wage in 1987 if compared with 1973, but a general decline occurred in it with the tight resource situation at the macro level beginning in the years 1983, 1984 and 1985 as seen from Table 23 and Figure 19.

Effects of Adjustment Policy on Incomes

From our point of view incomes and wages will be affected by the adjustment policies in Egypt and the reform at the macro level, which finally will affect the demand on food and health services as well. This may be investigated by studying the income effects of the agricultural policy reform for rural and urban households and the effects of the adjustment policies on the employment opportunities and thus the rate of growth in wages.

Figure 19. Real Wages (1973 - 100)

Source: World Bank, Poverty Alleviation and Adjustment in Egypt, Main Report, 1991

Income Effects of the Reform in the Agricultural Policy

In an attempt to estimate the likely impact of agricultural policy reform one can make use of the results of the extensive study of Dethier (1989). In this study, income effect of price intervention for rural and urban households are estimated.

In rural areas five household categories were analyzed: (1) landless households; (2) land holding households, farm size (0 to 1) feddans; (3) land holding households farm size (1-3) feddans; (4) land holding households, farm size (3-5) feddans; (5) land holding households, greater than 5 feddans.

All the results are presented in terms of the percentage change from the actual level of real incomes as shown in Table 26.

Data in Table 26 show that real income of landless households was higher than what it would have been if there had been no direct government price intervention. For landless rural households, exchange rate and trade have accentuated the welfare gains, or dampened the losses injured through direct price intervention. The negative impact on farm incomes of price policy was significant because of high world prices for traded agricultural products. Significant differences in welfare losses may be found among farms of different sizes. These differences are attributable to differences in cropping pattern as seen in Table 27.

Income Effects for Urban Households

Real incomes of urban households are affected by agricultural price intervention in the short run through a change in their consumer price index.

Table (26)

Effect of agricultural pricing policies on the real income of landless households.

Period Average	Direct Effect	Total Effect
1973 - 79	16.4%	27.9%
1980 - 85	13.7%	31.0%

SOURCE: Dethier (1989) P. 137.

NOTE: A value of say 10% indicates that, with interventions on prices of cotton, rice, wheat, maize, and sugarcane, real incomes are 10% higher than what they would have been, if prices had been at their border price equivalent with the exchange rate measured at official (direct effect) or at equilibrium (total effects).

Table (27)

Effect of Agricultural Pricing Policies on Real Incomes of Farm Households

Farm Size	Direct Effect				Short Run Average	Total Effect Effect on Income
	0-1	1-3	3-5	>5		0-1	1-3	3-5	>5	Ave
1973-79	-25.7%	-38.3%	-45.4%	-46.5%	-40.4%	-50%	-59.6%	-60.9%	-60.9%	-53.45%
1980-85	-10.1%	-22.7%	-29.7%	-30.6%	-24.7%	-28%	-41%	-50%	-52.8%	-44.25

SOURCE: Dethier (1989) P. 141

Low-income urban households have benefitted more from government price policy than have high-income households. The welfare gains are a function of the share of food items in the consumer budget. The share of wheat products (flour, and bread) alone is 13 percent for poor households, but only 4 percent for rich households. This explains to a large extent why low-income groups stand to loose relatively more than high income groups in case of removing price controls and other forms of government intervention in agriculture.

The results in Table 29 indicate that in the aggregate, consumption levels of cereals would have been lower, and sugar higher, if direct and indirect price intervention had been removed. Negative numbers imply that consumption would be lower if total intervention was removed and positive numbers indicate that consumption would be higher. Adding substitution effects to the computations would also modify the results, but probably not by much (Dethier, 1985).

It should be noted that the elasticities used for wheat and maize are high. Using the LES estimates of Von Braun and de Haen (1983) that is, -0.13 for both wheat and maize-would yield much smaller aggregate consumption effects but still the negative effects hold true. Lastly but not least, the results show that the ration system has a significant effect on income. This income transfer reduces the relative inequality of income by giving higher proportion shares to the poor. Thus, elimination or reduction of food subsidies and rationing system will hurt the poor segment of the population. The IFPRI and the Institute of Planning household survey conducted in 1981/82 revealed that urban residents obtain an annual transfer of L.E 17 per capita from subsidized wheat products, while rural residents obtain more than LE 12 directly from government channels and an additional LE 5 or 6 through the open market channels.

The relation of income and calorie deficiencies reported in Alderman and Braun, as well as the moderately high income elasticities for calories in Egypt (about 0.2 overall and about 0.4 for the poorest quartile) are evidence that the calorie deficit population would increase if the current income transfers and price subsidies were removed.

With Respect to Employment Opportunities as one of the determinants of income levels and its rates of growth, one may argue that they will be directly affected by the reform policies, especially in the public and government sector. The effects can be summarized as follows:

- Employment guarantee policies in the public economic enterprises since 1981 created a tight formal labour market.

- A net decline in the size of labour force in the industrial public sector, in the years 1982/83 and 1984/85 was noted. This trend is assumed to be prevailing in the late eighties with the application of reform policies (Nassar, H., 1989).

- A general decline in the rate of growth of employment in the public industrial sector from 3,6% on average for the period 1966/67-1974 to (-0,6%) over the period 1982/83-1984/85 was detected (Nassar, H., 1991).

- A general decline occurred in the rate of growth of employment in the government sector from 16.8% on average over the period 1982/83-1984/85 to 7,9% on average over the period 1985/86 - 1986/87. This declining trend will not be compensated by the encouragement of the industrial private industrial sector through the privatization wave, due to the relatively high capital labour ratio in this sector and its low labour absorptive capacity (545 in 1981/82 base year 1970/71 in comparison to 224.1 for the whole industry) (Nassar H., 1989). The same consideration may be applied on the investment and joint ventures in Egypt (Nassar H., 1991).

- An increase in the unemployment rate in the eighties when compared with the seventies was found (Figure 20).

- A significant decrease in the rate of growth of the wages for employees in the government sector was remarkable from 11,7% on average in the period 1982/83-1984/85 to -7,2% in 1985 in -5,3% in 1986/87 (El Shura Council, 1987). This trend associated with the increase in prices must affect the demand on food and the nutritional status.

- The above mentioned implications are applicable on the employees in the formal sector. Its implications on the employees in the informal sector depends on the different interrelations between the formal and informal sector which needs a survey study of both markets. (Nassar H., 1991).

Prices of Food and the Egyptian Ration System and Subsidies

Prices of food in Egypt is difficult to discuss, if we do not take into consideration the changes in the ration and food subsidy system, which was presented previously.

Figure 20. % OF UNEMPLOYMENT

Table (28)

Effect of Agricultural Pricing Policies on the Real Income of urban households.

Period Average	Direct effect			Total effect
	Low income	Middle income	High income	Low income	Middle income	High income
1973-79	37.9%	32.0%	14.5%	71%	60.2%	32.6%
1980-85	53.2%	45.7%	20.5%	114.6%	99.5%	57%

Source: Dethier (1989).

Table (29)

Effects of Total Price Intervention on Consumption (Period Averages, Percentage Change of Actual Average Consumption)

Period	Rice	Wheat	Maize	Sugar
1973-79	-9.7	-18.99	-7.68	0.11
1980-85	-8.69	-20.7	-12.72	1.23

SOURCE: Dethier 1989

In an attempt to reduce the cost of the ration/food subsidy program in Egypt the government adopted some measures. The cost containment measures have involved three components: raising ration/subsidy prices, reducing the number of items included and reducing the quantities subsidized.

Table 24 App. presents recent data on the changes in the prices of rationed subsidized and open market commodities. The cost of the 1989/1990 ration program is approximately half that of the 1984/85 program (Kennedy, 1989).

It is important to note that the balady bread price increased by 150% during 1989. As well, the size of the loaf was reduced from 160 gm to 130 gm, which means an increase in the effective price per calorie purchased by the households from 0.003 piasters to 0.00% piasters.

The mix of subsidized foods has also changed, maize, beans and lentils are no longer provided at subsidized prices and the amount of government budget allocated to other food items has decreased.

The Impact of the Changes in the Ration System and Food Subsidy System on the Expenses of a Balanced Diet

An estimate of the least expenses of a balanced diet for the average Egyptian family i.e. the cost of the minimum food basket, was conducted by Egypt Nutrition Institute using the price list of food commodities in 1981 (Korayem, 1987). This was reevaluated using the price list of 1984 and 1989 (Hussein 1989). It was concluded that the least expenses on food of the Egyptian family was raised to a level between 425% for the urban and 391% for the rural family from 1981/82 to 1989. This rise in food cost is considered too high as compared to the increase in wages.

The Potential Effects of the Changes in the Ration/Subsidy and the Increase in the Prices of Food

According to (Alderman and Van Braun, 1984), average subsidies per capita per year amounted to L.E 29.6 in urban areas, and to L.E 19.7 in rural areas having access to rationed goods has provided households with significant income transfers not only from ration system but also from other government controlled food channels. Most households (93 percent) have a ration card and (95 percent) of households have regular access to the four rationed goods (rice, sugar, tea, and oil).

The price elasticities in Tables 25 and 26 App indicate that consumers of rice and sugar are not particularly responsive to price changes. Hence, reduction of the subsidies on these items will decrease both government outlay and consumer real income but will have only a small effect on total demand. On the other hand, the larger price elasticities for balady flour indicate that consumers reduce their consumption of it when its price rises.

Price elasticity estimates discussed above would support the view that recent increases in food prices might have per capita cut-backs in the quantities of many food items consumed by households, especially in the lowest income category of households who are already spending 75 percent of their, income on food. Also some recent evidence (CRS, 1989), suggested that the majority of households have been decreasing their food consumption in response to these food price increases.

Effects of the Changes in the Consumer Ration/Subsidy System as well as the Government's Agricultural Policy

It is expected that all consumers both rural and urban will be negatively affected by the elimination or reduction of subsidies and the increase in prices.

In the rural areas, live small farmers (less than 1 feddan and landless) will be negatively affected, since they are purchasers of food. Any increases in income due to the new agricultural policy will be out-weighted by food price increases. Large farmers should not be hurt as some of the proposed changes in agricultural pricing policies will benefit them. Increases in price paid to producers for cotton, rice, sugarcane during the next few years with the removal of farm input subsidies will have a positive net effect on large farmers (Table 30). However, it is important to note that large farmers (> 5 feddans) constitute only 6.5% of all households (Ministry of Agriculture).

Impact of the Increase in Prices on the Nutrition Status of Egyptians

To predict any impact of the increase in prices on the nutrition status of Egyptians one must examine the contribution of the food security scheme to the nutrition status of Egyptians. This is clearly depicted in the results of the study of Alderman and Van Braun (1984), Following results are of major importance:

- The ration system contributes with 19% and 15% sources of calories for the lower income categories in urban and rural areas, respectively.

- Flour and bread (the major subsidized items) represent 49% and 42% of the calorie intake sources for the lower income categories in urban and rural areas, respectively.

- The lower income categories in urban and rural areas have a calorie intake (2343 and 2798) far below the average for the highest income category (3174 and 3149) in urban and rural areas respectively.

Table (30)

Food Security Winners and Losers from changes in consumer and Agricultural Producer Policies.

	Rural Areas	Urban Areas
Landless laborer	-
Small farmer (< 1 feddan)	-
Medium farmer (1 - 5 feddan)	0 or weakly (-)
Large farmers (> 5 feddan)	+
Lowest Quartile		-
Second Quartile		weakly (-)
Third Quartile		0
Fourth Quartile		0

Source: World Bank Poverty Alleviation And Adjustment In Egypt. Report no. 8515-EGT Washington D.C: World Bank, 1990 P 107.

The result is rather dangerous if we take into consideration that poor families are spending 63% and 48% of their budget on food.

Behaviour of Families as result of Rising Food Prices; (Current Consumption (Food) vs Future Consumption (Health))

Households, as experiences in many other countries have shown, are expected to attempt to counter the effects of the increase in prices. One such coping mechanism is substitution among food items in the diet towards cheaper calories (Andersen, 1988). One should note that the adaptation is not possible for the lowest income urban household since they are already spending about 75 percent of their income on food.

In addition a study was conducted by the Nutrition Institute on 100 households from each of Cairo, Assyut and Beheira governorates to discuss the behaviour of families as result of rising food prices (Hussein, 1989).

The study revealed:

- The rise in income does not cope with the rise in food cost.

- Families resorted to reduction in food and non food items.

- As well as consumption of less expensive foods to substitute more expensive ones took place without considering the nutritive value, both quantity and quality of the diet was compromised.

- All members of the family were affected by reductions in quantity and quality of the diet

- The higher the level of education within the HH, the higher was the sum of expenditure on food.

- Within the group with the least per capita income; 25% of labourers stopped consuming meat completely while 50% of farmers stopped getting vegetables for cooking. More than 80% of families in this quartile reduced the amount of meat irrespective of the kind of occupation.

Food Consumption and Intake

The end result of the different policies and programs influencing demand and supply of food is the pattern of food consumption and intake.

Figure 21

Data on food consumption and intake can only be obtained through food consumption surveys. In this respect 3 national surveys will be referred to as well as 2 valuable longitudinal studies (Aly et al., 1981; Moussa, 1987; Abdou and Moussa, 1975; Galal et al., 1987). Summary information about these 4 studies is presented in Table 28 App.

Dietary Pattern and Habits

In a national study by the Ministry of Health (MOH), Health Profile of Egypt (HPE), (Health Interview Survey "HIS", 1978-1984), the following dietary pattern was stated (Moussa, 1987): (Figure 22).

- The group of starchy foods and cereals (mainly bread and rice) is consumed by more than 99 of all categories of population. Both were highly subsidized by the state and are subject to one or several price increases.

- In rural areas higher percentage of population consume dairy products, fresh vegetables and tea while all other food groups are consumed by higher percentage of population in urban areas; particularly meat, poultry or fish group and fruits (fish is least consumed within the group). Thus urban residents receive a higher proportion of subsidized meat, poultry and fish.

- The difference in quality of diet was minimal by age and sex.

- Change of quality of diet with occupation implies also changes with socio-economic status. It was shown that starchy food and cereals and drinking tea was highest consumed by farmers and labourers. With the higher scale of occupations; scientists and professionals there is higher consumption of better quality or more expensive foods as eggs, meat, poultry or fish as well as fruits.

- Energy food supply contribute with more than 60% of energy intake of pregnant and lactating females and reached 80% during spring at the expense of tissue building and protective foods. However tissue building foods contribute with about a quarter in all seasons and give lower shares in spring (Moussa, 1988).

- On the other hand, a distinct feature of the toddler diet is the high ratio of vegetable to animal sources of energy (89.7%). This vegetarian nature of toddlers diet may explain the poor digestibility and low bioavailability of protein as revealed by a nitrogen balance study. Apparent protein digestibility was 55 ± 13 and apparent net protein utilization was 24 ± 14 (Moussa et al., 1988).

Figure 22. PERCENTAGE OF POPULATION CONSUMING DIFFERENT FOOD ITEMS IN A 24-HOUR PERIOD IN DIFFERENT AREAS

Source: Health Profile of Egypt, Dietary Habits (Moussa, 1987)

- Type of bread consumed differs in urban and rural areas. In urban areas 93.3% of HHs consume wheat bread while the corresponding figure in rural areas is 67.1%.

- Type of sweets consumed still differ in urban and rural areas. Urban HHs consume more jam and rural HHs consume more molasses. Molasses mixed with tehineh (sesame butter) is a popular dish and of high nutritive value.

- More urban than rural HHs consume frozen meat (25.3% and 3.6%), canned meat (15.8% and 1.4%) and frozen fish (33.9% and 21.6%), respectively. As previously mentioned the subsidized items from this food is more available in the urban areas. These differences reflect rural/urban differences in socio-economic status as well. The question that is raised now is what is the impact of the previous pattern of consumption on nutrient intake.

- Finally, it was noted that percaput intake of subsidized animal foods per day constitute 10%, 11%, 20% and 2% for meat, poultry, fish and eggs, respectively. The share of urban residents in the subsidized food was almost seven times for meat (frozen) nine times for poultry (frozen), five times for fish (frozen) and 5 times for eggs (Table 29 App.) (Aly et al., 1981). This means that subsidized animal food was inframarginal which is not the case for bread and flour.

Quantitative adequacy is indicated by the capability of the diet to satisfy energy needs of the individual presented by percent of the recommended dietary allowances of energy "% RDA". Qualitative adequacy can be measured by the capability of the diet to satisfy protein and other nutrient RDA of the individual.

From the NFCS (Aly et al., 1981), it is shown that 63.7% of fathers and 67.0% of mothers get 100% or more of their RDA of energy, while 78.4% of fathers and 81.8% of mothers get 100% or more of RDA of protein. It was noted that inadequacy is more in energy than protein which applied also to dependent family members 2-18 years old. A larger proportion of fathers are deficient in energy and protein than mothers with energy deficiency more prominent. Energy and protein deficiency is more prevalent in urban than rural areas. Those who got 100% or more of their energy RDA were 57.4% of fathers and 63.0% of mothers in urban areas, while the respective figures in rural areas were 72.1% and 74.9%. Regarding protein adequacy; 76.2% of fathers and 81.9% of mothers in urban areas got 100% or more of their RDA while the corresponding figures in rural areas were 81.4% and 81.7%.

Some more detailed information was derived from the CRSP which was conducted in 1984/1985 in a rural community (Moussa et al., under publication). Results are means of four seasons. Quantitative adequacy of the diet, indicated by % RDA of energy > 90; covered almost 40% of the four targets; father, mother, schooler and preschooler. Severe energy inadequacy of the diet indicated by, < 60% RDA was least among mothers. Minor and moderate energy inadequacy of the diet (% RDA 60 - < 90) was prevalent among almost 40% of the targets. Over-intake of energy (> 110% RDA) ranged from 10.4% for schoolers to 16.1% for fathers, 18.7% for mothers and 21.7% for preschoolers.

Protein inadequacy of the diet is much less than energy inadequacy except in preschoolers (18 - 30 months) of whom 45% have % RDA of protein less than 90. This may be explained by surplus consumption of bread (protein source) by the other 3 targets. Due to diversified sources of protein and resulting essential amino acid supplementation, there is no protein quality problem in the Egyptian diet. Iron inadequacy of the diet is maximum among mothers, almost two thirds of mothers consume iron not enough to satisfy 90% of the specified RDA (WHO, 1974 and 1989). Almost one third of preschoolers get less than 90% of their RDA of iron. Less than 5% of fathers and almost 10% of schoolers get diets inadequate in iron. Almost 20-30% of the four targets satisfy their Vitamin A RDA. However, Vitamin A deficiency is not a public health problem in Egypt. Meanwhile only 30-35% of the four targets satisfy more than 90% of their RDA of riboflavin.

Contribution of Some Selected Food Groups to Total Percaput Energy and Protein Intake Per Day

Cereals are the main contributors of energy (61.2%) as well as protein (54.9%) intake per day in Egypt. Cereals together with legumes supplying about 65% of total energy and 62% of total protein intake per day can provide an ample amount of dietary fibers which is desirable for prevention of diet related non communicable diseases. However, energy derived from sweets and sugar (empty calories) is almost double the cut-off point recommended by WHO for prevention of diet related chronic non communicable diseases; 21.4% against 10% (WHO, 1990). All animal products provide 8.2% of total energy intake and 27.7% of total protein intake. Although contribution of animal protein to total is much higher than 20 years before when it used to be less than 10%, yet this level is still much lower than developed countries.

Nutrient Intake and Variation with Different Factors

The nutritive value of the average percaput daily diet as computed by different methods in Egypt is shown in Table 31. Dietary history during a month and 24 hours recall give data of food consumption while Food Balance Sheet and Ministry of Supplies estimates give figures of food availability.

Energy intake per capita per day is around 3000 Kcal which is comparable with developed countries. Total protein is around 90 gm per day which more than average requirement. However, the figures for animal protein intake per day are almost double as computed by consumption studies when compared with availability figures. The difference is most probably due to home produced poultry and dairy products. Actual figures for animal protein consumption are much higher than 20 years before. Increased consumption of animal protein sources refers also to increased consumption of saturated fat with increased risk of cardiovascular disease "C.V.D".

Variation in Energy and Protein Intake with Geographic Area

Clearly indicates the urban/rural socio-economic differences as represented in the "Strategy of Development from Above". Energy intake is almost near 3000 Kcal and is slightly higher in rural sector than urban. However, animal protein is much higher in urban than rural sector; 29.2 and 19.6 gm respectively Table 32.

Food consumption both from the quantitative and qualitative point of view varies in different governorates representing Upper and Lower Egypt as well as metropolitan areas of different socio-economic status, which was previously discussed. Upper Egypt (Sohag) had 23.7% of its HHs at the lowest level of percaput energy intake per day (less than 1500 Kcal). Alexandria a metropolitan had the least proportion of HHs at this low level (9.8%). At the highest level of percaput energy intake (more than 3000 Kcal per day), Alexandria got the highest proportion of HHs (42.6%). Still Sohag has the lowest proportion of HHs (18.7%) at this level. Around 50% -60% of HHs of all governorates in the sample had percaput energy intake within 1500-3000 Kcal per day.

Regarding the level of animal protein intake, Sohag (Upper Egypt) had the highest proportion of HHs (56.3%) at the lowest level (less than 10 gm per day). At the other end of the spectrum, Cairo a metropolitan had the greatest proportion of HHs (54.2%) at the highest level of animal protein intake; 30 gm per day and more. Almost 20-35% of HHs of all governorates had intermediate level of animal protein intake; 10-30 gm per day. Animal protein is a sensitive indicator of the quality of diet on which depend bioavailability of iron and other micronutrients (NFCS, Aly et al., 1981).

Variation With Physiological Status

In the CRSP study pregnant females were followed up monthly from fourth month of pregnancy till delivery then lactating mothers were followed up for 6 months (Galal et al., 1987, Abdel Ghany, 1986).

Moreover, about 50% of lactating mothers got energy not satisfying the recommended dietary allowances "RDA". A minority, about 12%, got less than 80% of RDA of protein. All lactating mothers got less than 60% of their RDA of calcium. Almost 90% got less than 60% of their iron RDA.

Variation with Income

In the National Food Consumption Study (NFCS) (Aly et al., 1981), as in many other surveys, a positive relation was observed between income and both quantity and quality of the diet as seen from Figure 23 and 24.

Table (31)

NUTRITIVE VALUE OF THE AVERAGE PERCAPUT DAILY DIET AS COMPUTED BY DIFFERENT METHODS IN EGYPT

Method	Energy (KCAL)	Protein (GM)
		Total	Animal
Dietary History During a Month	3306	107.6	26.7
24-Hour Recall and Sample Weighing	2922	86.1	23.3
Food Balance Sheet	3341	91.5	12.5
Ministry of Supplies	3906	102.0	13.6

SOURCE: National food consumption study, N.I., (Aly et. al, 1981)

Table (32)

Nutrient Percaput Intake Perday in Egypt (Household Food consumption in 24 Hours)

	Energy KCAL	Protein (GM)
		Total	Animal
Total Urban	2742	87.7	29.2
Total Rural	2985	84.1	19.6
Total Sample	2843	86.2	25.1

SOURCE: National food consumption study (NFCS), Egypt. N.I.. (Aly, et. al., 1981).

Developed from: NFCS of Egypt, N.I.. (Aly et. al., 1981).

Thus, the high incidence of poverty in Egypt, the tight labour market and the high rate of unemployment clarify the low level of the quantity and quality of the diet for a significant group of the population.

Variation with Education

With lower levels of education of the family head, there is also lowered quantity and quality of the diet in the NFCS (Aly et al., 1981). In households with illiterate fathers 22% have percaput energy intake below 1500 Kcal per day and 43.7% have percaput animal protein intake below 11 gm. However with university graduate fathers these percents are 7.8% and 9.8% respectively. The relation is also valid with mothers education. This, associated with the level of illiteracy for men (37.8%) and women (61.8%) clarifies the inadequacy of the Egyptian diet for a significant population size.

Variation with Family Size

With smaller family size the percaput intake of both energy and animal protein is higher than percaput intake in larger families (Aly et al., 1981). Figures 25 & 26 are developed from the NFCS and clearly illustrate this fact. The national figure for the average household family size was 5 in 1976 and 4.9 in 1986. This finding calls for extra efforts in the areas of family planning.

Infection in Egypt

Infection is one of the determinants of nutrition and health status of Egyptians. Diseases affecting the Egyptian population are:

Parasitic Diseases

The relation of parasites and malnutrition was studied in the Health Profile of Egypt "HPE" Health Examination Survey "HES" (Moussa, 1988a). In general there is a positive relationship between parasites and malnutrition. Urinary bilharziasis was highest among the group of third degree undernutrition. This may point to the effect of ecology and quality of life on both the prevalence of parasites and nutritional status. Ancylostoma is still of highest prevalence in the group of third degree undernutrition. Ascariasis was highest among the group affected by obesity, which points to more exposure to infection with more consumption of food. Amebiasis was of lowest prevalence among the group of normal weight for age.

However, the general trend in Egypt is that parasite load is getting lower in the last decade, particularly ancylostomiasis and bilharziasis.

Gastro Intestinal Diseases

Although the incidence of intestinal diseases is on the decline still infection exists all over Egypt. Diarrheal diseases present one of the most important health problems in Egypt. Lack of potable water, insufficient refrigeration, lack of sanitary control of slaughter houses, presence of flies and improper disposal of wastes and refuse keep the incidence of these diseases very high.

However, Figure 3 indicates an on going declining trend in the mortality rates through diarrhea in the eighties, if compared with the seventies.

Figure 25. Percentage Distribution of Households by Family Size and Energy Intake

Developed from: NFCS, N.I., Egypt (Aly et. al., 1981)

Developed from: NFCS, N.I., Egypt, (Aly et. al., 1981).

Beside infantile diarrhea, there are other diseases, such as measles, mumps, whooping cough, chicken pox and german measles, which occur with moderate incidence but frequently in epidemic forms. Official registration data show a declining trend in all these diseases, though there are some under-reporting. Other diseases that have declined lately in occurrence and are subject to control campaigns are typhoid, malaria, trachoma, tuberculosis. In spite of serious effort and better care at the maternal and child health centres and units, trachoma is still prevailing in relatively high rates in rural areas.

Acute respiratory diseases such as pneumonia and bronchitis were reported to be major causes of death in Egypt.

Other diseases that are subject to increasing control by Ministry of Health (MOH) is cholera, leprosy, hepatitis and tetanus. Rate of prevalence of leprosy is estimated by 4.1 per thousand and is relatively high in Upper Egypt Poor sanitary conditions, overcrowding and inadequate nutrition is responsible for maintaining tuberculosis still a serious problem especially among the underprivileged groups. Unsafe water supplies especially in rural areas and urban slums lead to increasing infections by typhoid, paratyphoid and infective hepatitis. Anemia is widespread among school children. Table 33 reveals a declining trend in the incidence rate of several diseases.

Table (33)

Incidence Rate of Some Disease in Egypt (per 100,000 inh.)

Disease		1980	1988	1989
Diphteria		0.8		0.2
Pertussis		0.1		0.01
Tetanus	(Ages Unspecified)	10.8		10.1
	Neonatal (per 100,000)		315	187.6
Poliomyelitis		0.8		0.3
Measles		2.0		7.8
TB		3.9		2.8
Bilharziasis		19.7 (1983)		15.8

SOURCE: WHO, EMRO and Department of Health Information and Statistics, MOH Egypt, 1991.

Chronic diseases such as rheumatic heart disease, coronary heart disease and cancer are serious diseases leading to death.

Environmental diseases grew in importance and the government since 1969 initiated new controls on industrial pollution especially in the control of waste water effluents from municipal sewers and industrial plants and in the control of solid waste disposal.

Health System in Egypt

Health policies in Egypt over the seventies and eighties were influenced by the political and economic situation. As a constitutional responsibility of the government all citizens in Egypt are assured to have a comprehensive health care through the national health care system provided to them for a nominal registration per contact. The Egyptian government attempts to meet her responsibility towards the health of the people by operating a national health care system which comprises three main sectors, the government sector, the public sector and the private sector. Figure 27 represents the health services in Egypt. The Ministry of Health (MOH) is the main provider of health services in Egypt and is the only provider of health services in rural areas as well as the only institution responsible for the provision of preventive health care in Egypt. 63.5% of all hospital beds in Egypt in 1989 are MOH hospitals. If we add to this percent the teaching hospitals' beds, the ratio will increase to 70.01% (MOH, 1989). The MOH system is relevant to the government structure. Health care in Egypt is provided at three levels the central (national) governorate and the village level (Figure 28). Throughout the whole system there are no referral requirements, the individual can request health care at any government facility he chooses.

Figure 27. Health Services in Egypt

Figure 28a. M.O.H Services

Figure 28b. Village Hospitals

It is important to note that the spread of free health services in the sixties in Egypt was one of the goals of the political regime in Egypt, as shown in part two. The changes in the health policies in Egypt over the seventies and eighties had several implications on the health priorities in Egypt and implicitly affected the health status of Egyptians.

Health Policies and Priorities in the Seventies and Eighties

In the sixties and seventies high priority was given to the accomplishments of large scale projects. The early sixties witnessed a large campaign to construct new general hospitals, chest diseases hospitals, the Institute of Nutrition and other institutes. In the mid seventies a reconstruction effort was initiated to renovate all public hospitals.

Thus, the Egyptian health system was mainly considered curative oriented and physician oriented, despite the fact that the major health problems in Egypt are mainly endemic and amenable to protection rather than to curative action. This fact was responsible for the relatively low progress in the eradication of many communicable diseases, such as diarrhea before the mid-eighties.

Moreover, the primary health care approach in Egyptian health plans and policies before the eighties took a comprehensive approach (mass programs) to establish widespread centers and units all over the country offering basic health care. Only in the mid eighties the MOH changed its policy and chose a selective approach towards major health problems by emphasizing selective programs affecting target groups, such as diarrhea and immunization campaigns. From our point of view the latter change in health policies had a positive effect on the health status of targeted population, as seen from infant mortality rates.

In addition health planning in Egypt in the sixties and seventies has been based on a rough measure using projected population growth for estimating the size and number of buildings to be constructed. This kind of planning does not deal with such possibilities as changes in the organization and delivery of health care. In addition the population might be changing by the composition of its age structure and sex ratio. Children till the age of five have a much higher incidence of illness. This is why the change in the health priorities since the mid-eighties towards targeted programs favouring infants and children had several positive impacts.

Due to the curative oriented system and the relatively high capital intensity, imbalances between resources and needs emerged, which resulted in an increase in population exceeding the increase in physical resources, so that neither coverage nor utilization could be achieved. This is manifested in the trends of health expenditure, bed/population ratios in the eighties if compared with the sixties and seventies.

Another factor which may explain the relatively low health levels in upper Egypt and especially rural upper Egypt is the geographical inequality in the distribution of health services (Table 33). This is again a result of relatively limited resources and the expansion of mass programs in the sixties and seventies to achieve a coverage goal. The public health system in the sixties and seventies in Egypt is a low quality and poorly targeted program, designed to provide curative medicine for urban areas rather than simple preventive care for target groups and areas such as Upper rural Egypt.

Since the mid eighties health policies in Egypt witnessed major changes shifting from emphasizing free services for all the population to support the approach of introducing charges in the governmental curative health care facilities. This led to the adoption of two main programs.

Social Health Insurance (Badran, A., 1989) was extended to cover all populations and the number of facilities available for beneficiaries was increased.

The enhancement of a cost recovery program. The goal of this program is to achieve self sufficiency in fifty MOH profitable operation of 90% of project supported private medical practices, increase availability of pre paid health financing schemes such as insurance and health maintenance organizations, improve cost effective services available for 2,5 million users of the Health Insurance Organization and the Curative Care Organization (USAID, 1988). At this stage, it is important to note that the rationalization of public expenditure reflects both: the changes in the economic and political environment towards liberalization and privatization since the mid eighties - as well as the tight resource situation and the relatively high budget deficits and trade balance deficits, as indicated from Tables 13 and 14. Thus a sharp decline in the total expenditure as percent of GDP occurred since 1983/84 which was also reflected on the expenditure in the health sector. Moreover the growing external debt burden and the significant resource gap that was previously discussed necessitated the attempt to depress public expenditure and the search for cost containment projects in the public health sector.

Effects of the Changes in the Health Policies Over the Seventies and Eighties on the Health Sector

Imbalances between Declining Fiscal Measures and Growing Health Care Needs and Costs

Due to the limited size of resources health expenditure as a ratio of total public budget declined from 8% in 1970/71 to 2% in 1984/85 as indicated in fig 29. This declining trend is apparent also in the ratio of health expenditure to GDP which declined from 1.3% in 1970 to 1% in 1988/89 (Figure 30).

However per capita health expenditure on health services declined in real terms in the period after 1980/86 compared with the increase in this indicator in the seventies. Table 34 reveals a significant difference between health expenditure per capita in real terms and in monetary terms.

Concerning physical and human inputs there is a general decline in the beds/population ratios in the eighties, in comparison to the ratio prevailing in the seventies as indicated from Table 35.

However, the distribution of health manpower/population does not show the same trend. The data of health manpower show the substantial investment in health manpower training programs undertaken by the Egyptian government during the past three decades. They also reflect the acceleration of graduate students enrollment in medicine schools. Despite the obvious increase in health manpower/population, Egypt is still deficient in some areas of health manpower with respect to quantity of personnel as well as quality especially for health assistants. The distribution of physicians and nurses among various activities of MOH reveals the low number of doctors and nurses in school health, maternal and child health and preventive services. Doctors and nurses, in all rural health services, where 56% of the population live, represent 20% of all physicians and 26% of total number of nurses in MOH. There is a slight increase in the coverage rate of rural population by rural health units in the eighties, however the targeted ratio was not achieved (1:5000).

Maldistribution of Health Services

Table 36 chronicles the distribution of health units as well as health personnel, beds by governorates. Disparities among urban lower and upper Egypt is clear as well as between upper and lower Egypt.

This reflects the Strategy of Development from Above and public policy design as indicated by the PQL1 in Table 3. All the previous indicators may explain the differences in health and nutrition standards by regions.

Figure 29. M.O.H BUDGET TO GDP

Figure 30. EXPENDITURE AS % OF THE BUDGET

Table (34)

MOH BUDGET AND HEALTH EXPENDITURE PER CAPITA IN FIXED PRICES (000)

YEAR	MOH BUDGET IN CURRENT PRICES	MOH BUDGET IN FIXED PRICES	POPULATION	PER CAPITA HEALTH EXP. IN CURRENT PRICES	PER CAPITA HEALTH EXP. IN FIXED PRICES	RATE OF ANNUAL INCREASE OF HEALTH EXP. IN FIXED PRICES	RATE OF ANNUAL INCREASE OF HEALTH EXP. PER CAPITA IN FIXED PRICE
1975	67723	157851	37016	1,83	426
1976	87909	174583	38198	2,3	4,57	10,6	7,27
1977	95092	169504	39183	2,43	4,33	-2,9	-5,25
1978	117417	182610	40192	2,92	4,54	-7,7	4,81
1979	131191	173533	41230	3,26	4,21	-4,9	-7,3
1980	179462	203471	42289	4,24	4,81	17,3	14,3
83/84	331102	278237	45886	7,22	6,06
84/85	374477	290067	47000	7,97	6,17	4,3	1,8
85/86	402576	208384	48575	8,28	5,52	-10,5	-10,5
86/87	427252	237098	49012	8,47	4,84	-11,7	-12,3
87/88	477284	220719	50355	9,47	4,38	-9,5	-9,5

Calculated from MOH, The Golden Book of the MOH, 1936 - 1986

SOURCE: The Index numbers from the Publications of the Central Agency for Public Mobilization and Statistics.

Table (35)

Human and Material Resources

		1970	1980	1986
Beds/1000 inh
	MOH	1.57	1.43	1.29
	National	2.14	2	2.00
Physician/1000		5.7	11.8	17.3
Nurses/1000		4.9	7.6	14.7
Pharmacist/1000		1.82	4.34
Rural Health Unit/Per.		10782		10143

SOURCE: MOH, Department for Information

Table (36)

Geographical Distribution of Health Services

Region Indicator	Bed/10000 inh		Health Expenditure	Physician/100000	Nurse/100000
	MOH	National	1987/88	1985	1985
Urban Gov.	1,9	2,9	17,596	8,108	7,42
Lower Egypt Gov.	1,3	1,6	11,22	5,25	3,29
Upper Egypt Gov.	1,17	1,45	9,11	5,25	2,8

SOURCE: Calculated from MOH, Department for Status Information, 1990

Despite the fact of a significant increase in the primary health indicators as indicated in Table 37 basic health services are still low (Badran. A. 1988).

Table (37)

Primary Health Care Indicators

Indicator		Ratio %	(Year)	Ratio %	(Year)
% Infants Fully Immunized
	- DPT (3 doses)	89	(1981)	86,4	(1990)
	- Polio (3 doses)	69	(1981)	87	(1990)
	- Measles	66	(1981)	86	(1990)
	- BCG	78	(1981)	87.8	(1990)
% of Pregnant Women Given Tetanus Toxoid (2 doses)		10	(1981)	49	(1988)
% of Pop. Receiving Health Care by Trained Period
	- Pregnant Women Total	40	(1982)	52	(1988)
	- Urban/Rural	44/37	(1982)	68/42	(1988)
% of Pregnant Women Delivered by Trained Personnel
	- Total	21	(1978)	35	(1988)
	- Urban/Rural	47/5	(1978)	56/19	(1988)
In Institutions:
	- Total	11	(1978)	24	(1988)
	- Urban/Rural	22/2	(1978)	40/11	(1988)

SOURCE: WHO/EMRO and Department of Statistics and Information, MOH, Egypt, 1991.

Low Incentive System

Low pay and incentive system lead to the following results:

- unfilled capacities in training nursing schools, low average quality in some categories of health assistants, short working lives for nurses and a definite shortage of nurses relative to physicians;

- low pay in government services, coupled with high rates of earnings available in private practice affects incentives for high performance in government services;

- Lack of management, supervision and discipline make the public system unable to redress the low job performance of government health workers stemming from poor training, lack of complementary supplies and low pay.

Main Health Interventions

From our point of view health interventions are recently basic components of the national health delivery system. Main health interventions are stated below:

National Control of Diarrheal Disease Program "NCDDP"

Control of diarrheal diseases has long been a concern of the Egyptian MOH. One major step was taken in 1978 when the MOH began to distribute ORS to its health units. Another step was taken in 1982 with the establishment of NCDDP which began pilot activities in Alexandria Governorate in 1983 and has began full national activities in March 1984. The National Diarrheal Disease Control Program officially started in September 1981, with collaborative funding from Egyptian Government and US-AID. The program continued for 10 years to be institutionalized from first of October 1991 as one department of Ministry of Health "MOH" carrying out the same activities as NCDDP.

The Specific Objectives of the Program Were

- to reduce mortality, due to diarrhea, of children less than five years of age by 25% in a five years period;

- to raise proportion of mothers oriented about oral rehydration therapy "ORT" to 90% and perception of correct use of oral rehydration solution "ORS" to 75%;

- to ensure treatment of at least 50% of acute diarrhea cases in the MOH units through ORT.

- Impact on Knowledge, Attitude and Practice "KAP" of Mothers Regarding Diarrhea Management was evident

- Through targeted field studies it was found that percentage of mothers who used ORS in treatment of diarrhea was 17% during 1980, 37% during 1983 and reached 79% during 1990.

- Percentage of mothers who stopped breast-feeding during diarrheal episode was 58% during 1980, 41% during 1983, and reached 5% during 1989. This is expected to be of major impact on improvement of nutritional status of children less than two years of age.

- Percentage of mothers who can mix ORS correctly was only 12% during 1983, while during 1988 it reached 88% (NCDDP, 1991 and Nagaty, 1988).

Impact on Cases of Severe Dehydration Among Children

In the pediatric hospital of Azhar University in Cairo there was 71% reduction of cases of acute dehydration from 1984 to 1990. In Al Shatby pediatric hospital of Alexandria University hospital reduction reached 75% from 1983 to 1990.

Impact on Infant and 1-4 Year Child Mortality Due to Diarrhea

From year 1984 to 1989 there was a tremendous reduction in infant and 1-4 year child mortality in general and due to diarrhea in particular where reductions reached 65.4% for infants and 72.9% for children Figure 3. Since 1985 acute respiratory infections "ARI" has become the main health problem. Reductions in mortalities due to diarrhea are expected to be associated with improvement in nutritional and health status of infants and preschool age children.

Child Survival Project (CSP)

The MOH started the (CSP) in 1986 and is on going for at least 9 years. A national goal of universal child immunization (UCI) by July 23, 1987, was adopted. This was the first component of the CSP. A national survey carried out in November 1987 by WHO, UNICEF & MOH showed that Egypt has reached its 80% target in all antigens except BCG (tuberculoses) and measles. Comparing the coverage rates from 1984 survey, there was a considerable rise in coverage even in BCG & measles.

A tetanus toxoid campaign during November and December 1988 was designed targeting 1 million 3-9 month pregnant women. Those who received the second dose were 82%. The campaign was successful due to the ability of television to diffuse such messages. Another successful national campaign for tetanus toxoid was carried out during November and December 1989, again targeting 1 million pregnant women. Both campaigns raised awareness as well as coverage.

During 1990 Egypt vaccination coverage survey was conducted. The results showed that the fully immunized children were 76.4%, partially immunized 21.0% & non-immunized were 2.6%.

The 1990 survey provided for the first time measurement of those children who according to the dates on their vaccination cards, received the necessary doses of vaccine before their first birthday. Those figures are: BCG 86.1%., OPV3 83.8%., DPT3 83.3%., Measles 78.4%.

Acute Respiratory Infection (ARI) Control and Prevention

This project is the second component of the Child Survival Project.

Its objectives are:

1. To reduce infant and child (under 5 years) mortality due to acute respiratory infections by 20% through early detection and proper management of acute respiratory infections.

2. Prevention of acute respiratory infections among children.

Child Spacing: (3rd component of the Child Survival Project)

Objectives:

1. reduction of maternal and child mortality;
2. reduction of maternal morbidity;
3. promotion of MCH services;
4. raising health awareness among women for practicing child spacing.

Its objectives is to deliver nutrition services routinely at all PHC units all over the country to the target groups, by appropriately trained personnel as part of the institutionalized integrated program. By the end of the project span, prevalence rates of different forms of malnutrition should be reduced at least by 50% e.g. PEM & iron deficiency anemia.

Human Resources Development and Training

Beside nutrition training of the health team included in many projects of MOH, the Nutrition Institute "N.I", in collaboration with WHO conducts short training courses on different vital components of nutrition in PHC. The trainees include different levels of MOH personnel central, governorate and peripheral levels as well as different qualifications; physicians, dictations and nurses.

Other Health Projects with Nutrition Implication

Family planning activities have been intensified during the 1980s. Educated and working mothers are the sector who benefitted most. Reducing family size as well as child spacing are expected to have positive effect on nutritional status of both mothers and children.

Strengthening Rural Health Services as well as Development of Urban Health Delivery System Projects with combined funding for Egyptian government and USAID were implemented during the early 1980s. Both projects included upgrading of PHC units including supply of weighing scales and growth charts for growth monitoring. In the Development of Urban Health Delivery System Project training kitchens were also established in model health centres in Cairo and Alexandria. Both projects activities included nutrition training of the health teams with resulting improvement in the nutrition component of the PHC system.

The Urban Delivery System Development Project established a Centre for Social and Preventive Medicine "CSPM" which is located in the premises of Pediatric hospital of Cairo University and operated by the Pediatric Department, Faculty of Medicine. CSPM has started its activities in the late 1980s with a well established nutrition component. It is a model training centre for the different specialties of the health team.

Finally, there is a public awareness of the importance of nutritional and health problems which was indicated in the First National Workshop on Food and Nutrition Surveillance that was held in May 1990.

Family Health History (Caring Capacity)

Family health history is considered as one of the basic determinants of health and nutrition status. In this concept several factors play a role such as: caring capacity, child spacing, women's role, nutrition related interventions. Different programs and policies are relevant in this category like educational policies, family planning policies, nutrition intervention programs and health education.

Tradition

In general women in Egypt have equal rights with men in the educational field and employment rights. Moreover Islamic women (the greatest share of women population) have dependent financial and property states. As woman in Islam can keep her family name after marriage, she can be a guardian over minors and can bring legal suit without the approval of her husband. However, all previous factors did not change the traditional image of women in Egypt, who are in a low subordinate status especially in rural areas, in comparison to men. This is because of the following factors (Sayed, 1988):

- the husband's power in divorce and in custody over the children;
- the unequal female inheritance and testimony in comparison to men;
- the mistranslation of many of the legal rights of islamic women.

Intra familial food distribution

Intra-familial food distribution was studied in an Egyptian village during the four seasons, Ramadan fast, feast, and Bayrum (Moussa et al., under publication).

The mean of the seven occasions of the target food intake (n = 1478) showed that the father gets 32.0%, the mother 28.8%, the schooler 23.6% and preschooler 15.6% of total energy consumed by the four targets. These ratios are almost matching with ratios of reference recommended dietary allowance "RDA" for energy (WHO/FAO/UNU, 1985). Protein and other micronutrients were all correlating with energy. However with iron, the situation was different. The father got 32.9% of total iron intake of the four targets while according to RDA for iron (WHO, 1974 and WHO, 1989) he should have got only 15.4%. With the mother, the reverse was true. She got 29.1% of the intake of the four targets while according to her RDA, adapted for local bioavailability of iron, she should have got 48.8%. This discrepancy may be attributed to the documented fact that the father in the Egyptian rural setting is privileged with the high quality expensive nutritious food items available in the HH.

Caring Capacity

The concept of caring capacity is an essential element of good nutrition and health. Malnutrition frequently occurs despite a household having access to appropriate sanitation and health services. While adequate income, greater food availability and expanded health services are necessary for improved nutrition, these will not likely to be sufficient to lead to such improvements unless households are able to capitalize on them. In addition to an enhanced caring capacity at the household level, nutrition improvements for disadvantaged and vulnerable groups may also depend on societies capacity and willingness to assist them.

Caring capacity may be reflected at two levels: the quality of the individual and family care within the household and the degree of national commitment at the community level.

Within the Household

Providing individual care within the household is an important aspect of human behaviour, and the level of care given is based on household resources and the attitudes of those who control these resources. The household heads and primary - care providers also require capacity, in terms of time, knowledge, energy and motivation, to ensure the equitable well being of all and to put their knowledge into practice (FAO/WHO, 1990).

The knowledge attitude and practice of household members particularly of the household head and the primary care provider, largely determines the nutritional status of the household. This may be explained by the educational status of women.

Education Policies in Egypt and Female Educational Level

After 1952, the Egyptian government encouraged the education system to make it accessible to all social classes of the population (Kandil, A., 1989). There is an impressive expansion of the educational system especially that there is a compulsory education law that requires the children to attend elementary and preparatory level. Attendance of school, if only for a relatively short period has become the usual experience of Egyptian children. Number of children in primary education increased by an annual rate of 5.1%. Secondary education enrollment increased by 9.1% on average and higher education enrollment increased by 7.1% over the same period. Despite of all efforts, total enrollment ratio is still low. 10% - 20% the primary school age population remain still out of school. Total enrollment ratio is relatively low for female rather than male. Moreover there is a high drop and repetition between 10% and 15%. Those who drop out in the primary education are still illiterate or can hardly read and write. They are coming from the poorest socio-economic groups. Proportion of girls in primary education increased from 38% in 1972/73 to just 44.1% in 1985/86 (World Bank, 1990). Illiteracy rates of women is still found relatively high. 61.3% of women are illiterate and about two quarters can just read and write as indicated in the last census (Figure 31).

Female illiteracy was found related to poverty. Incidence of poverty is relatively high in rural upper Egypt, where female illiteracy is also high (86.7% vs 22.3% in Greater Cairo, 26,7% in Alexandria 31.4% in total urban and 84.2% in total rural areas) (CAPMAS, 1990).

Figure 31. Illiteracy In Egypt

Implications of the Educational Status of Women on Infant Mortality and Use of Health Services

Much malnutrition is attributable to inadequate understanding of the body's food needs. This was proven by the results of Table 38. Though food is available at the household but child did not get his RDA (Moussa et al., 1988-b, Moussa 1990).

Table (38)

Quantitative and Qualitative of Child Diet in Comparison to Family Diet

	No.	% of RDA of Child to that of his Family
		Both are < 100%	Both are > 100%	Child < 100% Family > 100%	Child > 100% Family < 100%
Energy	214	53.8	8.4	26.6	11.2
Protein	214	31.8	10.3	43.9	14.9

SOURCE: National Food Consumption Study, Nutrition Institute N.I. Ministry of Health MOH. Egypt, 1981.

Maternal education usually is connected with greater use of health services, lower fertility and more child centered care giving behaviours. In the low income sample of mostly uneducated mothers only around one tenth of mothers gave extra care to the child more than the rest of HH members. With increasing education, women have more power within the family to allocate resources on food and other expenditure for their children's health and welfare (Sayed et al., 1989).

Child Care Giving Practices and Educational Level

Child care was studied in a rural community within the comprehensive study on Food Intake and Human Functions (Noor et al., 1991). The study was based on a longitudinal assessment of child care-giving practices of 158 mothers over a period of one year. Time sampling and behavioural observation methods were employed to obtain data on eleven specific child care-giving activities performed by the mother. These categories of activities were: attending to illness, breast-feeding, clothing care, feeding holding/carrying, playing/entertainment, practicing personal hygiene, preparing food, serving food, socializing, supervising/instructing/mediating (Figure 32). The children concerned were toddlers from 18-30 months. Results revealed mothers spent 23.3% of their time holding or carrying toddlers. 15.5% of their time supervising/instructing/mediating, and 11.0% in preparing food for toddlers. Mothers who spent more time in fostering child's safety were from the higher socio-economic status group; their toddlers had better personal hygiene scores and there were fewer children in the households. These mothers also consumed more food considered to be of good quality such as animal source food. Time spent by mothers in attending to illness correlated negatively with household sanitation and the mothers years of formal education. This possibly reflected the greater morbidity burden of the toddlers of these mothers. Education of mothers was associated positively with the lime they devoted to child care-giving.

Other Implications of the Educational Status of Women

Moreover the mother's educational attainment is positively related to the immunization coverage rates. The proportion fully immunized varied from around 25% among children whose mothers have never attended school to 54% among children whose mothers have a secondary education (DHS 1988. Sayed et al., 1989).

In addition, proportion of children having diarrhea in the last seven days, who were not given any treatment and did not benefit from medical advice was 36.9% for children of mothers with no education and 26.3% for children with mothers who have completed secondary and higher education.

Rural/Urban Differences in Caring Capacity

Rural/urban differences in socio-economic development indicators are reflected on the caring capacity. The behaviour of mothers towards seeking medical advice for treatment of diarrhea and respiration infection reveals wide differences between urban and rural Egypt In general one third of the sample children who suffered of diarrhea in the last seven days were not given any treatment and mothers did not ask for medical advice in spite of available health services. That proportion was highest in rural areas especially of upper Egypt (40.5%) and lowest with mothers working for cash (28.1%). Moreover urban/rural residence are more closely associated with the likelihood that a child will be immunized. In rural areas only 20% of children 12-23 months with a birth record have received the complete primary course of immunization compared with more than 50% in urban areas, whereas it reaches 9% only in rural upper Egypt and 62% in the urban governorates (DHS, Sayed, et al. 1989) (Figure 33). Moreover, Figure 34 shows rural urban differences in infant mortality.

Figure 32

Employment Status and Caring Capacity

The sub-model of women in the labour information system project (Za'louk, M. 1990) indicates that the majority of female workers are in the category of non paid household workers (60%). This category reaches 73.7% of all female workers. 80% of the females in this work status are illiterate. This might be explained by the conservative behaviour of women in Egypt and the shortage in employment opportunities in the formal sector. The survey also show a bias against female with respect to the paid work. Only 26.4% of the employed female population were in this category (66.7% in urban areas vs. 12% in rural areas). It was interesting in this survey to know that 84.5% of the males and 77.8% of the females believed that women with younger children should not work. Also 87.6% of the males and 82.7% of the females believed that women should not work, if her income is not needed by family. This belief, coupled with the increasing tightness in the formal labour market and the increase in the rate of unemployment in the eighties will affect the creation of productive employment for women. Agriculture is the economic activity number one for females (67%), next comes the service sector and the third economic sector is manufacturing.

Differences in the work status of mothers are also reflected on the percent of children 12-23 months reported as having received full coverage with immunization ranges between 88.5% for children of mothers working for cash and 74.4% for children of working mothers not paid in cash. The same pattern of differences is prevailing among the children of 12-23 months, having a birth record seen by the interviewer (60.7% for children of mothers working for cash and 55.3% for children of working mothers not paid in cash) (DHS, 1988, Sayed et al., 1989).

Figure 33. Under Five Mortality by Place of Residence

Egypt DHS 1988

Figure 34. Percent Fully Immunized by Place of Residence

Egypt DHS 1988

Caring Capacity Within the Society

In any community, there will be people who are unable to adequately take care of themselves. These may include displaced persons, isolated elderly orphans and the disabled. Ensuring the nutritional well being of these groups requires adequate support and assistance from the local communities, local and national governorates, civil and religious groups and NGOs. To some extent this is taken care in Egypt through the Ministry of Health, Ministry of Social Affairs, NGOs and religious groups. Within the law of 79 in 1955 retired people may have some price exemptions in transportation and are included in the health insurance. Subsidies and credits for retired people can be obtained through Nasser Bank and some special aid is occasionally distributed. Some houses for elderly people have been established in recent years, however still there is shortage in such services and in special health clinics for the elderly (National Centre for Social and Criminological Research, 1985).

Direct transfer payments are made by the government in Egypt, through the Ministry of Social Affairs and by NGOs. Moreover, the Ministry has another scheme called Productive Families Program. This program is an employment income generating program for poor families. Several assumptions indicated the national coverage of the poorest groups through government payments assistance schemes is about 1:5 persons (World Bank, 1990).

It is important to note that the social assistance scheme is small in total funds. The total average payment is LE 57 per annum in 1988/89, which is less than an adequate subsistence payment. As payments are very low, there is still a discrepancy in the numbers between those who apply for support and the vulnerable groups. NGOs in Egypt have a long history. They are philanthropic in nature rather than developmental and are regulated by the government under law No 32/1964. The financial affairs of NGOs are subject to government regulation. The government gives approx. LE 6 million per annum on the operational grants given to the NGOs from the Ministry of Social Affairs. With scarce information it was indicated that total expenditure of NGO were eight times the subvention from the government It has been estimated that the government and NGOs are together providing about LE 60 million nationally. This amount should be increased four fold to provide an income satisfying basic needs for one adult.

Environment

Environmental sanitation and health behaviour of care takers are important contributing factors to the incidence of infections.

In Egypt percentage of population covered by safe water supply was 100 in urban and 49 in rural areas during 1982. These proportions were changed to 95 and 75 in 1985 then improved to 100 and 90 in 1987 respectively.

Percentage of population covered by adequate sanitary facilities (sewage disposal mainly) was 95 in urban areas and 42 in rural areas during 1982, deteriorated to 77 and 7 respectively in 1985 and improved to 100 and 65 during 1987 (WHO/EMRO, 1991) (Table 39).

If we know that the morbidity load in Egypt particularly in preschool children is indicated mainly by diarrhea and respiratory infections the previous environmental indicators are still low in rural areas. This ratio is misleading if we take into consideration the low percentage of households with purified water in Egypt as indicated in Table 2 App.

Table (39)

% of Population with Safe Water Supply and Adequate Sanitary Facilities

Year	% Population with Safe Water Supply			% Population with Adequate Sanitary Facilities
	Urban	Rural	Total	Urban	Rural	Total
1982	100	49	75	95	42	69
1985	95	75	84	77	7	37
1987	100	90	95	100	65	80

SOURCE: WHO/EMRO, 1991

Infant and Child Feeding

Status of breast Feeding

There are several studies which have been conducted in Egypt to tackle this subject. However, we will be only concerned with national studies on representative sample of Egypt. Data are drawn from ARE Nutritional Status Survey (N.I/CDC/AID, 1978) of which feeding and weaning practices were studied for 4282 children less than 3 years. Another study on feeding and weaning practices of infants and children less than two years was conducted by Egypt Nutrition Institute "N.I" in collaboration with WHO during 1981. The study included six governorates; Cairo and Alexandria as well as two governorates from each of upper and lower Egypt; at least 250 children from each governorate were studied. The DHS, 1988 (Sayed et al.) included breast feeding information on 5174 child less than 3 years of age.

There are important differences in feeding practices of children under 2 years of age between rural and urban populations and between general urban population and the less privileged populations of Cairo, Giza and Alexandria Children in rural areas are exclusively breast fed longer and completely weaned at a later age than the general population of urban children. The pattern of feeding in early childhood in the less privileged urban areas is closer to the rural pattern than the general urban pattern. These differences suggest that among rural and less privileged urban mothers, traditional patterns remain influential or that the availability of weaning foods, either actual or in terms of cost, is less.

Results of the three studies are rather similar. More than two thirds of infants at one year of age are still breast fed and 30% approaching their second year of age continue to be breast fed. Breast feeding more than two years is uncommon, less than 10%.

Trends in breast-feeding show a decreasing awareness of this phenomenon in Egypt. In 1984 (Sayed et al., 1984) the mean duration of months of breast-feeding was 18.8 and declined to 17.3 in 1988 (Sayed et al., 1988). Moreover the mean duration of months of breast-fed children for mothers with no education was 22.8. This figure declined also for those with some primary education from 18.5 to 15.8.

Figures 35 A & B derived from EDHS, 1988 show pattern of breast feeding and weaning among children by geographic areas and educational level. Duration of breast-feeding was longer for women in rural areas and those with lower educational attainment This might be explained with the relatively higher engagement of women of higher education and in urban areas with outgoing work period.

Weaning foods

Under normal circumstances breast milk provides all energy and nutrients needed by the infant for the first four to six months of life. Afterwards, additional food must be introduced so that the infant gradually and progressively adapts to the full adult diet. Due to several biologic and environmental factors, the weaning period is one of the most critical periods in child's life particularly in developing countries.

* Nature:

The prevailing types of weaning foods in Egypt belong predominantly to five main categories; mammalian, milk and products, consumed by 69.6% of children less than 2 years as well as portion of the family diet and preparations as biscuits and other processed cereals. Only about one fifth of children in the weaning period consume a diet specially prepared daily for the child or commercially prepared weaning foods. In the age period less than six months home prepared cereals mostly wheat and rice as well as starch puddings are used. Feeding infants with water and sugar is a custom in some rural areas of Egypt. More weaning foods are gradually introduced and by the age period 18-24 months more varieties are used by a higher percentage of children to include more food groups; legumes, tubers, fats and oils, eggs, meat or chicken, vegetables and fruits. Animal products, fruits and commercially prepared weaning foods including "Supramine" are used by a proportion of children not exceeding 20% (Moussa et al., 1988a, Moussa, 1990).

* Adequacy:

In a study on low socio-economic group of the population; by the N.I. on children less than 2 years of age, the contribution of the child diet to satisfy his recommended dietary allowances of energy and protein "% RDA", based on recommendations of WHO/FAO/UNU (1985), was compared with "% RDA" percaput in the same child family.

The study revealed that 53.8% and 31.8% of children and their families do not satisfy RDA for energy and protein respectively. This shows that energy inadequacy is even a more serious problem than protein inadequacy. This group suffering of poverty will partially benefit from nutrition education stressing how to prepare balanced recipes from cheap available resources. For 26.6% of cases, energy RDA of family is satisfied but not the child. For protein this sector reaches 43.9% of the study sample (Table 38). For this group, nutrition education will have full benefit as food is available at the household but the mother is unaware of the appropriate child needs. Those families who give more care to the child than to themselves are a minority not exceeding 14% (Moussa et al., 1988 b; Moussa, 1990).

Moreover, one of the main factors which cause inadequacy of the child diet in the weaning period is that it is mostly part of the family diet which is mostly vegetarian with high amount of dietary fibres. Also gruels, specially prepared for the child from cereals or both cereals and legumes, become bulky and of high viscosity by cooking. The mother resorts to more dilution to keep it semisolid with resulting lowering of energy and nutrient density. As revealed in some studies the majority of children less than two years of age get diets which are with less energy density and with less protein energy ratio than their families. The ratio reaches 66.5% for energy density E.D. and 65.4% for protein energy ratio P/E% (Moussa et al., 1988b, Moussa, 1990).

Figure 35A. Duration of Breastfeeding and Postpartum Insusceptibility by Place of Residence

Egypt DHS 1988

Figure 35B. Duration of Breastfeeding and Postpartum Insusceptibility by Level of Education

Egypt DHS 1988

Family Planning Policies and Child Spacing

Family planning programs and child spacing were found positively correlated with the nutrition status of children. Egypt in comparison to other countries has relatively reliable data of population size fertility and mortality levels, has a support for slowing population growth by public commitment and its institutional base is also relative well built (World Bank, 1985).

Family planning policy in Egypt changed several times since 1965 (USAID, 1986). In 1966 an executive Board of Family Planning was established with programs launched through the Ministry of Health facilities to increase the availability of family planning services. Between 1973-80 the emphasis was shifted towards the socio-economic approach to fertility reduction. In December 1980 the Population and Family Planning Board issued a comprehensive strategy statement calling for a reduction in the fertility rate to 20% i.e. a 50% reduction by the year 2000. The impact of family planning programs on fertility levels will not be discussed here. The impact of family planning programs on family health status can be indicated examining their effects on the ideal birth intervals. Birth intervals appear to have a significant influence on the health status of mothers and their children. Nawar et al., (1986) reported that spacing of birth, the avoidance of higher order births beside other factors are needed as a means of reducing infant and child mortality in Egypt It was argued that short birth intervals; particularly those less than two years was positively associated with higher rates of both morbidity and mortality among women and their children. In 1984 it was indicated that 40.5% of the Egyptian surveyed women generally prefer an interval of between one to two years between births (ECPS, 1984, Sayed et al., 1985). The mean ideal birth interval is somewhat higher among women from urban areas (37.5%) particularly in the urban governorates (39.2%) than among women in rural areas (31.8%) especially in upper Egypt (32.6%). All previous information indicate the necessity to increase the efforts to educate Egyptian women about the importance of birth intervals on child mortality especially in rural areas.

It is difficult to compare the results of 1984 with the results of DHS (1988) as the exact period of the interval was not stated in the last survey. However Figure 36 shows another indicator the desire for children. All women expressed a desire for a child and only 11.9% want to delay the birth at least two years. Among women, who have one child, almost one half of the women would like to wait two years before having another child. The wish to limit childbearing ranges between 52% among women with two children to over 80% among women with four or more children. Regional and urban differences in percent of women wanting no more children is remarkable as seen from Table 31 App.

It is believed that the differences in the nutrition and health status of mothers awareness of birth spacing and birth intervals should be raised as one of the determinants for better health and nutrition status of mothers and children.

Nutritional and Health Interventions Affecting Family Health

Food Aid

For over 30 years assistance was provided to Egypt through International Organizations, mainly the World Food Program (WFP) and relief agencies such as KARE and the Catholic Relief Services (CRS), as well as from some countries as Holland, Finland, etc. The nature of the assistance included substantial quantities of school children particularly in rural areas as well as new settlers on land reclamation projects.

Figure 36. Desire for Children - Currently Married Women

Egypt DHS 1988

Impact of wheat soya blend "WSB", donated by CRS to MCH centres for supplementary feeding, on nutritional status of less than 3 years children was evaluated at the Rehabilitation Unit of the Nutrition Institute of Egypt "RUNI" (Aly et al., 1976). The group fed WSB had better growth velocity than the control group fed the traditional supplements.

Currently, assistance programs are designed to eradicate dependence and promote self-reliance through socio-economic development.

Nutrition Education

Mass Media

Dissemination of nutrition and health information through radio and television programs, newspapers, magazines and books is going on since a long time. Messages are improved and became effective as evidenced by those broadcasted for control of diarrhea, feeding during diarrheal episodes, immunization campaigns, family planning, good healthful nutrition and its importance to pregnant and nursing mothers, etc. Radio and television sets are available now in almost all homes in urban and rural areas. The Nutrition Institute staff members participate in all mass media campaigns. Specialized university and faculty staff members have their own educational activities in several programs on mass media.

Nutrition Education at School: The school feeding program in Egypt

School feeding programs are intended for improvement of health and food habits through nutrition education. A complete hot cooked meal was offered free in state schools since 1942. This was substituted later on by a dry (Oslo) meal. Milk products from USA were used to improve the nutritive value of the meal since 1954-55. About 2 million children benefitted from this program which was stopped after 1 year. Since then it was maintained in a continuous or satisfactory way for reasons related to war conditions in the Middle East. It was stopped after 1967 and resumed gradually after 1971-72. Almost 3 millions benefitted from it by 1977-78. They constitute almost half the school children (Said and Aly, 1986).

Evaluation of the school lunch program in Technical Secondary Schools of ARE (Aly et al., 1976) showed that the dry meal supplies about one third of the daily nutrient requirements. The meal was beneficial to health and nutritional status of the children as evidenced by improvement in growth measurements mainly heights, weights, left mid-arm circumference and left triceps skinfold thickness as well as decline in prevalence of deficiency signs. The educational and learning capabilities of the children improved significantly. School attendance increased with better attention and behaviour during classes.

Nutrition Education at Primary Health Care (PHC) Centres and Units for Mothers

The project seeks the development and testing a practical nutrition education program that teaches mothers how to improve the nutritional status of their family members especially their children.

Phase 1 started in August 1979 by a grant agreement between the Ministry of Health (MOH) of Egypt and the Catholic Relief Services (CRS). The Nutrition Institute (NI) was assigned the responsibility of project implementation.

Phase 2 started in July 1983 to extend coverage to more health centres within governorates already served and to encompass 6 additional governorates not served in Phase 1. Phase 2 incorporated in its design some significant refinements.

Evaluation of the project showed that the project created awareness both in urban and rural communities as to the importance of nutrition in the overall health aspects. The effect of nutrition education versus supplementary feeding on the nutritional status of young children was studied by Demain (1981). The study was conducted in out patient clinic of N.I. as well as 2 MCH centres in Cairo on 498 under two years children. The results revealed that nutrition education of mothers to prepare low cost weaning food from available resources had better effect than giving donated supplements on growth of children. However both nutrition education and supplementation had better effect on nutritional status of the children than feeding on the traditional inadequate weaning foods.

Promotion of Appropriate Low Cost Weaning Foods

Lack of suitable weaning foods for low income groups is one of the important causal factors leading to child malnutrition. Consequently several weaning food mixes were developed and evaluated experimentally. Popularization of the developed weaning foods: mainly sesamena and arabena is going on through the national nutrition education program initiated by the Nutrition Institute (NI) staff all over Egypt. During nutrition education of mothers, stress is made to explain the bases for preparation of an adequate meal for the child. Quantitative adequacy is based on WHO/FAO/UNU recommended dietary allowances (RDA) of energy. Qualitative adequacy is based on the intelligent blending of food groups so that the recipe will supply high quality protein to promote growth with adequate amounts of vitamins and minerals satisfying RDA.

Also mothers are educated about what, when and how to feed their children during weaning and post-weaning periods. This is delivered within a package of integrated health and nutrition services by PHC staff in most parts of Egypt and by NI staff at the Rehabilitation Unit of the nutrition Institute (RUNI).

It was the first time in Egypt to evaluate a newly developed weaning food in a comprehensive manner starting with chemical and biological evaluation and proceeding to nitrogen balance studies with effects on growth of infants and young children. Some results are:

1. The percent standard weight for age has improved substantially in a period of 6 months.

2. Third degree undernutrition dropped from 11.3% to 0.8%, second degree from 25.2% to 13.8% and obesity disappeared after 6 months of health and nutrition care. Normal, first degree and overweight cases increased.

3. Catch-up growth is achieved with the package of health and nutrition care stressing suitable weaning foods.

A comprehensive research program on the functioning consequences of iron deficiency included 250 families in a semi-urban area near Cairo (Bortos) by Hussein et al (1988). Anemia defined as hemoglobin concentration less than 11 gm for preschool age children and less than 12 gm for school age children occurred in 30.7% of preschool children and in 34.1% of school age children. The mean hemoglobin concentration was 11.7 ± 1.58% and 12.5 ± 1.6 gm for preschool and school age children, respectively before the intervention. Hemoglobin concentration increased to 12.9 ± 1.2 gm and 13.7 ± 1.5 gm, respectively after the provision of iron supplementation.