In the incubator wards of public hospitals and some private hospitals, many mothers face a daily struggle to obtain the “Alveofact” injection, used to treat respiratory distress in premature infants whose lungs have not fully developed. Finding a single ampoule of this drug often takes long hours because of its shortage in the market, even though it is considered one of the essential treatments for reducing respiratory complications in this group of children.

About 1.9 million children are born in Egypt every year, according to official statistics issued in 2024, while World Health Organization data indicate that complications related to premature birth account for about 20% of all deaths of children under the age of five in Egypt, which reflects the scale and seriousness of the problem. Despite the absence of a precise official statistic determining the proportion of premature births out of total births, based on the known global rates (between 5% and 18%), it can be estimated that between 95,000 and 342,000 children are born prematurely in Egypt every year.

Alveofact is one of the most important medicines available in Egypt for treating acute respiratory distress syndrome in premature infants, a medical emergency that threatens the lives of infants born before their lungs are fully developed. Normally, the foetal lung secretes a substance called pulmonary surfactant, which prevents the air sacs from collapsing during breathing, but when a child is born early, this secretion is often not yet complete, leading to respiratory failure in which the infant needs urgent support, and the only medicine capable of saving the infant is the Alveofact injection.

The price of the Alveofact injection in the Egyptian market has jumped repeatedly in recent years: it is currently sold in a number of pharmacies for about EGP 6,635 per vial, while other pricing lists indicate that it recently reached EGP 7,400 after the latest update in September 2024, whereas earlier records showed that the price hovered around only EGP 4,400–4,700 a few years ago.

A simple calculation shows that the price of the injection has risen by between 50% and 57% over about five years, a huge increase given that it is a life-saving medicine with no available alternative in the Egyptian market. This means that the family of any premature child who needs the drug is forced to face an exorbitant cost, given its limited availability in public hospitals.

It should be noted that the medicine is one of the imported drugs that depend on foreign production technologies (it is derived from bovine lung as a natural source of surfactant), which makes it more sensitive to changes in the exchange rate and customs costs, as well as to import and distribution policies. Nevertheless, the price disparity between public hospitals and the private sector raises additional questions about pricing and distribution mechanisms.

What makes the crisis even more serious is that this medicine has no approved alternative in the local market, and no Egyptian company produces an equivalent to date. According to the testimonies of neonatal paediatricians who spoke to us, “every minute of delay in giving the injection to the infant may mean fatal complications or loss of life”.

Mahmoud Fouad, director of the Egyptian Center for the Right to Medicine, sets out for us a map of the most prominent hospitals that have recorded deaths of newborns in the recent period because the drug was unavailable: El-Shatby University Hospital, El-Demerdash University Hospital, Sharq El-Madina Hospital, Mansoura International Hospital and the Assiut University Children’s Hospital, in addition to the Nasser Institute Hospital, Mit Ghamr Hospital in Dakahlia and Damanhour Teaching Hospital. Appeals for help are also coming from the Mesna Abu Hummus Specialised Children’s Hospital, El-Ahrar Teaching Hospital and El-Galaa Teaching Hospital, as well as the Mersal Charity Association, the Suez Canal University Teaching Hospital and El-Hayah Hospital in Port Said.

A responsible source inside the Ministry of Health acknowledged the crisis in a brief conversation with us but refused to talk about it, while another source asked that the question be put to the Egyptian Drug Authority rather than to the Ministry of Health. Zawia3 contacted 3 officials inside the Drug Authority to learn the details of the crisis, but we were unable to obtain a clarification as of the time of writing.

The injection is for those who can afford it!

A pharmacist source who spoke to Zawia3, preferring not to be named, reveals that this type of injection “comes in two concentrations; the official price of the first is approximately EGP 6500, while the price of the second reaches EGP 7500”, noting that the drug is currently relatively available in the market, but he points out that “the crisis peaked just two months ago, when the medicine disappeared completely and the price of the injection on the black market rose to about 12,000 pounds”.

The pharmacist describes the importance of the drug as a matter of “life or death, quite simply”, explaining: “The presence of the injection means the child has a chance to survive, while its absence may lead to death, God forbid.” He explains that “the parallel market played an exceptional role during the crisis, despite its illegality: “Some traders imported the drug from abroad to save the lives of children, and they were keen to offer it at acceptable prices, not equal to the official price of course, but much closer to it. They insisted that the aim was not profit but saving the lives of the little ones”.

He concludes: “What these traders did, even though it is outside the legal framework, helped fill a deadly gap. Had we waited for the state to act through its official channels, it would have taken a long time, and in the meantime many children might have lost their lives”.

Why are these medicines important?

Dr. Samar Reda, a consultant in paediatrics and neonatology, explains in an interview with Zawia3 that premature infants face a range of health risks at birth, foremost among them respiratory distress syndrome (RDS), one of the most common and most serious problems in this group.

According to Samar, this syndrome occurs as a result of the absence or deficiency of a natural substance called surfactant, which the foetus’s body begins to secrete between the twentieth and twenty-fourth week of pregnancy, and whose production is usually complete by the thirty-fourth week. Its importance lies in keeping the air sacs open during exhalation by reducing surface tension; children born before this gestational age are therefore more vulnerable to respiratory distress and the complications that follow from it.

Samar says that drugs such as Alveofact, Survanta and Curosurf are the cornerstone of saving these infants, as they make up for the deficiency of surfactant and directly help to improve gas exchange and reduce dependence on mechanical ventilators. These drugs also reduce the risk of severe complications such as chronic lung disease or internal brain haemorrhage, in addition to helping lower mortality rates associated with the syndrome, as numerous medical studies have shown.

The consultant in paediatrics and neonatology stresses in her conversation with us that these drugs can be given either preventively, immediately after birth, to infants at risk of the syndrome, or therapeutically, after the syndrome has been diagnosed through X-rays and the appearance of clinical symptoms.

Samar also explains that in some cases the child may need more than one dose depending on how the condition develops, stressing that the lives of premature infants are severely threatened if they do not receive these drugs, as they may suffer an acute lack of oxygen affecting the brain, heart and kidneys, or complete respiratory failure, and may even face the risk of death within the first hours or days after birth.

Children facing death

The testimonies we obtained from citizens in several governorates agree that the price of the medicine has doubled over the past years and that it is almost completely unavailable in public hospitals and health insurance units, while private hospitals and centres offer it at varying prices that families usually cannot afford.

Eman El-Sayed (32 years old), from Giza Governorate, says that her son was born in the seventh month and urgently needed an injection to expand his lungs; that was last April. She adds: “I thought the large public hospital where he was born would provide him with the treatment, but I was shocked to find that the injection was not available and had to be brought from outside the hospital.”

She recounts to us the ordeal of obtaining the medicine: her husband began an arduous search through dozens of pharmacies in Cairo and Giza, to no avail. Some private pharmacies offered the injection at a price approaching eight thousand pounds, while the official price is lower than that, which confronted the family with a cruel equation: either save the infant’s life at any price, or face the inevitable fate.

She adds: “I had to borrow from relatives to buy the injection through an intermediary, and when I handed it to the doctor he told me that this medicine should be available free of charge inside public hospitals, to save children like my son Ahmed, but the shortage of medicines in general has become a recurring crisis.”

From Giza to Alexandria, Sohag, Beheira and other governorates, the suffering remains the same. Madiha Ezzat tells us that her daughter was born in the thirty-second week and was admitted to the incubator unit of El-Shatby Hospital in Alexandria Governorate. After the initial examinations, she was informed that the infant needed an immediate lung-expansion injection.

She says: “The nurse told me that the injection was not available, and that if I had acquaintances who could bring it from outside the hospital, they should do so. I had just come out of a caesarean section, unable to move, while my husband was trying to raise the money. Then began an exhausting round of calls to friends and acquaintances to search for the injection,” adding: “Prices ranged between 7 and 7,500 pounds, depending on each pharmacy or intermediary. After a whole day of anxiety and breakdown, the family obtained the injection. The mother says: “Today Yara has turned two, but that experience was harsh and unforgettable”.

Doaa Abdel Barr likewise recounts that her son was born at Abu Hummus Hospital in Beheira Governorate and suffered from respiratory distress from the very first moment. “The doctors told me that the solution was the Alveofact injection, but the hospital did not have a single dose available. My husband tried to inquire with the administration and was told that the drug was on the Drug Authority’s lists but had not yet reached the hospital.”

Doaa adds: “We faced an impossible choice: either wait for the distribution or search for the injection outside the hospital. So we moved the child in a private ambulance to the Nasser Institute in Cairo for five thousand pounds, and on the way his condition deteriorated because of the delay.”

But the shock did not end there: even at the Nasser Institute, the injection was not available. The search continued until the husband found it at a private pharmacy in the Mohandessin area for six thousand eight hundred pounds, higher than the official price. She adds: “The doctors were able to give my son the injection, and he later recovered, but I came out of the experience with a bitter feeling that the lives of premature children hang on pure chance: whether or not the family finds the medicine in time.”

Safaa El-Bakry, from Sohag, says that her child was born in the thirty-first week suffering from acute respiratory distress, and the doctors told her he had to be given the lung-completion injection immediately, but she was shocked to find it unavailable at the university hospital. Her husband had to search the pharmacies of Sohag and Assiut to no avail, until a relative in Cairo stepped in to provide it at a price exceeding seven thousand pounds. She adds: “Hassan survived thanks to the injection, but the experience showed me that obtaining medicine in Upper Egypt is much harder, as if our children’s lives were a lower priority.”

The mothers’ testimonies intersect with the findings of field research conducted by Zawia3 on the availability and prices of the Alveofact injection and other lung-completion drugs in the Egyptian market. We contacted 10 major pharmacies in Cairo, Giza, Alexandria, Mansoura and Sohag; most of them confirmed that the drug had been unavailable for months, while three of them offered to procure it through “intermediaries” or “private warehouses” at prices that in all cases exceed the official price of EGP 6635. The actual offers we received ranged between EGP 7000 and EGP 8000 per injection.

The Drug Authority acknowledges the importance of the medicine as “life-saving”

In September 2023, the Egyptian Drug Authority issued an official directive to healthcare providers regarding pulmonary surfactant drugs, which are used to treat respiratory distress syndrome in premature infants, among them Alveofact. In its statement, the Authority stressed the need for strict adherence to monitoring and documentation procedures when administering these injections, given their extreme sensitivity and their direct impact on the lives of newborns.

The Authority asked doctors to fill in a special follow-up form for each case given surfactant, including detailed data on the treatment and the results of medical tests before and after administration, in addition to close monitoring of heart rate and oxygen saturation and an attempt to wean the child off the ventilator immediately after the injection.

The Authority based its recommendations on the 2022 European guidelines for the treatment of respiratory distress syndrome (RDS), which affirm that administering surfactant improves survival rates and reduces complications such as pneumothorax. It also recommended following modern techniques for administering the drug, such as the IN-SUR-E technique or less invasive methods (LISA), with the aim of reducing the lung damage associated with intubation.

These recommendations reveal that Alveofact and similar drugs are classified as life-saving medicines, but that their handling in Egypt is subject to strict medical controls focused on safe use inside incubator units, while the Authority made no reference in its statement to the question of the medicine’s availability or how easily hospitals can obtain it, which leaves a gap between the protocols and the reality on the ground in the health sector.

A dangerous gap in the Egyptian medicine market

Mahmoud Fouad, director of the Egyptian Center for the Right to Medicine, affirms in an interview with Zawia3 that over two weeks he documented a list of medicines that have no alternatives in the Egyptian market, describing the matter as “a major disaster”, since these medicines are life-saving. He points out that the list includes three of the most important heart medicines, currently unavailable, in addition to the drug “Alveofact”, intended for premature infants, which is the only available treatment for respiratory distress syndrome.

Fouad reveals that the price of the injection is about EGP 6000 and that it is imported from Germany, adding that he contacted sources inside the Drug Authority who confirmed that there is an actual stock of the drug, but that it is dispensed only on direct instructions from the head of the Authority or his deputy, without the reasons being explained. He comments: “There may be technical considerations that I do not know about, but what I know for certain is that there are hospitals issuing genuine appeals for help because children have died for lack of this life-saving injection.”

He continues: “How can a country like Egypt, which has more than 1 million and 600,000 births annually, face this shortage? Many of these newborns are admitted to incubators because of jaundice or incomplete lung development, and cases of incomplete lung development require the injection within 24 to 48 hours to save the infant’s life,” describing what is happening as a tragedy by any measure.

The centre’s director affirms in his conversation with us that he has already sent complaints and inquiries to the Prime Minister’s adviser about the crisis and has received no response to date, stressing that the issue affects every Egyptian family. He adds that Egypt needs about 4000 injections a year, while the available stock is far below that, pointing to an alternative product that is said to be launched soon at a price of up to 10,000 pounds per injection, which doubles the burden on families.

Fouad believes that the crisis reveals the extent of the neglect of the medicines file, not only where children are concerned but also with regard to life-saving medicines in general, citing the shortage of heart medicines, and asks: “How can a patient who suffers a heart attack, a clot or fibrillation not find his medicine in Egypt? This is completely unreasonable.”

The director of the Egyptian Center for the Right to Medicine criticises the performance of the Egyptian Drug Authority, explaining that the Authority generates revenues of up to 200 million pounds a month from medicine registration fees, while registering a new medicine takes no more than some paperwork and a cost estimated at one million pounds. He says: “The Authority’s role must be clear in confronting the shortage, especially since in the recent period, up until last April, it succeeded in addressing previous shortage crises and providing many imported medicines, despite the unprecedented price inflation that accompanied this. But for us to reach a point today where major hospitals are issuing appeals for help because of the absence of life-saving medicines, this raises an existential question: what do we do, then?”

Who holds the Drug Authority accountable?

Mahmoud Fouad, in his conversation with us, calls for an urgent investigation into the shortage of life-saving medicines, saying: “It is unacceptable that in Egypt we reach a stage where the stock of three essential medicines for treating heart disease is zero. A few hours ago, one of the senior cardiologists contacted me and confirmed that he has no information about when these medicines will be available, which puts doctors and patients alike in a dangerous predicament.”

He adds: “When the Drug Authority was established in 2019, the main goal was for us to have an accurate system for tracking the movement of medicines: the volume of local production, patients’ consumption rates, the size of the available surplus, as well as the strategic stock in the medical supply warehouses. These data are what enable the state to manage crises, whether in cases of war, pandemics or any other emergency, but unfortunately this role is still absent.”

Fouad stresses that “heart medicines in particular cannot tolerate any delay; there are diseases whose patients can wait days or even weeks, but for a heart patient, stopping the medicine may mean stopping life itself. The disappearance of these medicines from the market therefore represents a direct threat to the lives of thousands of patients.”

He continues: “Hence I call for an urgent investigation to determine how we reached a state of “zero stock” in essential heart medicines, and whether there were errors in inventory management or in estimating patients’ needs, because the absence of a clear map of Egyptians’ consumption of medicines is the root of the crisis; if the Authority had accurate data on the number of patients and their needs, it would be easy to determine the volume of production required and to ensure that no deadly gaps occur in the availability of medicines”.

In the recent period, Egypt has been suffering from a major crisis involving the disappearance of dozens of medicines used to treat chronic diseases as a result of the rise in the dollar exchange rate, exceeding about a thousand products, most notably medicines for high blood pressure, diabetes, heart disease, the gallbladder, the thyroid, the kidneys and stomach disorders, in addition to medicines for Mediterranean fever, cancer, nasal drops for infants and adults, and medicines for colds and gynaecological diseases. Estimates by the head of the Chamber of Pharmaceutical Industries at the Federation of Egyptian Industries, Gamal El-Leithy, in media statements last February, indicate that the shortage of medicines in the market ranges between 30% and 40%, including 15% of medicines for which no alternatives are available.

The Egyptian medicine market comprises about 17,000 pharmaceutical products manufactured by around 170 factories. Despite the increase in the prices of about 400 medicines, by 20 to 30% for medicines intended to treat chronic diseases and by between 30 and 50% for non-essential and seasonal medicines, medicine sales in Egypt reached about EGP 215 billion in 2024, compared with EGP 154.7 billion in 2023, reflecting an increase estimated at about 40%, according to estimates by the head of the Pharmaceuticals Division at the Federation of Egyptian Chambers of Commerce, Ali Ouf. He also predicted in earlier statements that the Egyptian Drug Authority would raise the prices of only about 1000 pharmaceutical products during 2025.

As for the number of pharmacists, it is estimated at about 213,000 pharmacists working in 80,000 pharmacies nationwide. According to the World Health Organization, the ratio of pharmacists to population in Egypt is one pharmacist for every 438 citizens, while the global rate ranges between one pharmacist for every 1,100–1,600 individuals, or the equivalent of 23 pharmacists per 10,000 citizens. As for pharmacies, there is one pharmacy for every 1,261 citizens in Egypt, compared with the global rate, which ranges between one pharmacy for every 3,500–5,000 individuals.

Where children’s medicines are concerned, the crisis is no longer merely a shortage of medicine in a market staggering under dollar fluctuations and import and pricing policies; it has become a moral and humanitarian question about the value of life in Egypt.

Thousands of infants are born every year before their lungs are fully developed; some survive by chance, if their family is lucky enough to have the money or the connections to secure the injection, while the names of others quietly disappear from the incubator records because of a dose that was missing or a box that was not released.

The absence of a life-saving medicine such as Alveofact is therefore not merely a medicine crisis, but a mirror of a deeper flaw in the system of the right to treatment, in which the premature infant remains suspended between his first breaths and the chance that his family will find an ampoule of life.

Editorial correction: The first version of the report stated that the Egyptian Drug Authority’s directive on surfactant drugs was issued in September 2021; the correct date is September 2023. The 2021 date is the date of issue of the form attached to it.

Editorial correction: The first version of this report and its chart stated that about 380,000 children face the risk of early death before the age of five from complications of preterm birth, according to World Health Organization estimates. That figure does not appear in WHO data, which attributes about 21% of deaths of children under five in Egypt to preterm birth complications, according to its Eastern Mediterranean Regional Office, so it has been removed.

☆ Add Zawia3 to your preferred sources on Google