Costs of supplies, equipment and maintenance are rising along with patient numbers, forcing doctors at the National Heart Institute to court charity to bridge a growing financial gap Abdul Hamid Mohamed lies still on a bed covered with a barely clean sheet as a cluster of doctors check the cardiac monitor and a circulating nurse lays out bandages and instruments. The digital heartbeat goes pop, pop, pop, 70 beats a minute, steady, the doctors say finally. Mohamed, a 52-year-old with the yellow eyes and skin of a typical heart patient has pericardial effusion, “a water in the heart,” as he describes his disease. His case is an abnormal accumulation of fluid in the sack around the heart, which puts pressure on the organ, causing it to function poorly. If left untreated, pericardial effusion can cause heart failure or death. After several weeks of difficulty breathing, sharp pain radiating between the chest, neck, shoulder, back or abdomen, a feeling of tightness, occasional fainting and nausea, going through a surgery for draining the pericardium had become an unavoidable option. But there is something that could have saved him from such risky a operation, though is not easily accessed by the country's poor: regular medical attention. Some of the 700-1300 daily visitors to the National Heart Institute in Imbaba might not be as lucky as Mohamed. “Sometimes, patients go on very long waiting list that may last for weeks and sometimes months, just to get treatment,” Dr. Amr El-Ghandouri, cardiologist at the Heart Institute told Ahram Online. “As we stand here, there are some patients waiting til the end of August and September just to do a diagnostic cardiology, a very simple procedure that if you have the right equipment could be finished much earlier.” What seem like endless queues, extending up to three kilometres down the street, of patients and their families lining up to get the basic treatment for their most vital organ is not a shocking scene for hopeful patients here who can only afford full or half-funded medical services through Egypt's public hospitals. “I've been coming here for four or five consecutive weeks now to get an approval from the hospital authority to get treatment at the state expense,” says Gaber Hassan, one 35-year-old man standing in a very long row leading to the window. “Finally my son will have the treatment,” he says happily, cuddling Ali, his starving 3-year-old son who has glazed eyes and distended belly. Hassan, a carpenter, who came all the way from Beheira to get the treatment, didn't know that the corrective surgery needed to save the life of his only child, who has a congenital heart defect, is one of his basic rights. The World Health Organisation (WHO), of which Egypt is a member, recognises the ‘right to health' as one of the fundamental rights of every human being; it is defined as the right to enjoy "the highest attainable standard of health." This includes “the right to the underlying conditions of health as well as medical care.” Doctors at the Heart Institute, one of the 1,250 public hospitals that make up the state healthcare infrastructure in Egypt, have this week started a campaign to raise funds from charity organisations, as supplies are running hazardously low and staff doctors are getting overwhelmed and exhausted. “It's not shameful to try to raise some donations for the hospital,” says Dr Mohamed El-Badrawy, consultant cardiologist at the institute who, with other doctors is leading the fundraising campaign for the hospital. “What is really shameful is to turn down someone who asks for his basic right to health just because you're short of capabilities.” According to El-Badrawy, the institute can only serve 250 cases per day, which accounts only for 25 per cent of the average total cases they receive. Established in 1964, the National Heart Institute performs 12 to 15 open-heart surgeries a day, each costing LE20,000 ($3,351). While it receives a monthly fund of LE5 million ($837,953)from the government, their actual monthly expenditures are something closer to LE9 million ($1.5 million). “The health care spending is very little compared to the growing number of poor,” says Dr El-Badrawi, “and because you just cannot let go a patient in need, we're trying to raise funds and we really need the help and cooperation of the civil society and the community to save the lives of many poor.” According to the WHO, heart disease is the number one killer in Egypt, with the number of victims increasing on annual basis so that heart disease-related mortality reached 210,000 in 2009. “Poverty is the main reason behind the increasing number of heart-related diseases in Egypt,” says Dr. El-Badrawy. “Poverty means a wide array of problems including stress, endogamy and the lack of periodical treatment and regular check-ups, which can only be afforded by the rich.” This year, a sum of LE24.9 billion was allocated to healthcare spending, comprising 4.7 per cent of the total budget. “The ministry of finance has allocated for the year 2011/2012 around LE277.9 billion to satisfy the social dimension and provide the biggest amounts of funds to run services in education and health sectors and to support systems of subsidies, pensions and social security for citizens,” reads this year budget proposal. According to the statement, healthcare spending aims to ensure “health services for citizens and provide them with treatment requirements in hospitals and medical centres, taking into consideration improving the living standards of doctors and nurses.” Despite an increase in health care spending of LE1.6 billion ($268,142)for the fiscal year, the public health expenditure still weighs in far below internationally recommended levels. The appropriate average is 8 to 10 per cent of a state's budget according to the World Health Organization. While the healthcare spending has ranged from 1.5 to 4.8 per cent over the last decade, other sectors are often given much bigger pieces of cake. Defence and National Security, which includes military defence, along withinstitutions of public order and safety, including the ministry of interior and the police, make up for around 10 per cent of the wholebudget, more than double thefunds allocated to the Health care spending. Samer Soleiman, associate professor of political economy at AUC thinks the budget has long been politically, rather than socially oriented. “Four point eight per cent is a real weak percentage for the health care item,” says Soleiman. “If anything, it reflects the fact that healthcare and other social goals were never a priority.” For him, this is a natural extension of the spending scheme of the last three decades. “The sectors that receive the largest shares of the public budget are, to a great extent, the stronger political forces,” says Soleiman. “For instance, when we look at the Egyptian budget in the 1980s and 90s, we see a sharp increase in allocations to the ministry of interior, a reflection of the struggle between Islamist groups and the state at that time.” The budget share, according to Soleiman, of any particular sector largely depends on its ability to exert pressure and extract the required allocations. And because healthcare patients, especially “poor patients,” are the primary beneficiaries of health expenditures, they can never be dealt with as a political entity or effective lobby group. They are simply pushed down the priority list for budget drafting. For Soleiman, the way public budgets are planned in Egypt ignore the very simple principle of “budget unity,” wherein all spending and revenue-collecting parts should be related to each other and the whole. “The government should realise first its most important objectives and priorities and then collect taxes and start to redistribute them to the items of spending,” he says. “In Egypt, it actually works the other way around. The government collects taxes and revenues in order to distribute it to fixed items in the budget.” Back at the heart institute, it's not surprising then, that more than 50 per cent of the hospital resources come from charity. “We can't do without personal and charity organisations donations,” says Dr El-Badrawy. “When you have such a long, daily list of patients, most of them coming from rural areas, and you're forced to filter them out everyday just to be able to cover the most critical and urgent cases, then you have no other choice.” But for civil society and activists, charity is not an acceptable source of public spending. “Donations and charity can never be a source for publicly owned hospitals and institutions,” says Dr Alaa Ghanaam, the director of the Health and Human Rights Program at the Egyptian Initiative for Personal Rights (EIPR). “This should definitely be the role of the state.” The institute, according to doctors who complain of being overworked, suffers a deficiency in everything from human capital to the number of machines - many of them broken because of a lack of routine maintenance. “Normally, according to the manufacturer's instructions, [the catheterisation lab] should not be working more than 15 patients a day, but unfortunately because of the large number of patients visiting the institute every day it works for more than this,” says the young Dr. El-Ghandour. He points at one of two closed Cath-labs, the institute's main examination rooms with diagnostic imaging equipment, closed for more than three weeks because of broken machines. “I don't have a clear explanation for that, but having a very expensive machine that serves a big number of patients on a daily basis to be broken for more than three or four weeks is a big catastrophe in my opinion,” El-Ghandour adds. The inefficiency in allocating state resources is one of the main causes of the malfunctioning state of the public health sector. Even within healthcare spending, some 25 per cent goes to ministry of health facilities. Five per cent goes to social health insurance facilities, six per cent to private hospitals, a quarter to private clinics and 23 per cent to private pharmacies, says a 2009 EIPR report. The report, titled ‘Challenges Facing Health Expenditure in Egypt,' carries heavy criticism of the way Egypt's health budget is distributed. “Of the 2008/2009 LE11.2 billion ($1.88)total healthcare spending, allocations for basic materials did not exceed LE1.6 billion ($268,141), and only LE600 million ($100.6) was allocated to medications; an additional LE200 million ($33.5)was earmarked for patients' food needs, in addition to a very small percentage for serums and vaccines,” the report details. “These meager sums are wholly inadequate to these institutions' needs for medications and necessary serums.” The report also criticises the inequality in distributing health services across Egypt, creating a 67 per cent gap in public health spending between urban and rural areas of Egypt. “Although Upper Egypt has a higher number of individuals who cannot afford health care, it does not receive the majority of health spending; on the contrary, a higher percentage of spending goes to Egyptian urban areas,” the report adds. Additionally, at the time of the report, the lowest income bracket received only 16 per cent of public health spending, with the highest income bracket taking about 24 per cent. Adding on the private spending that goes to this highest income bracket, it's clear that this segment of society is unsurprisingly the largest recipient of health spending. There are also extreme discrepancies in the distribution of health services across various social sectors. The poorest fifth of society utilises 14.5 per cent of services from the Health Insurance Organization while the richest fifth consumes more than twice that. The poorest 20 per cent of society use only 13 per cent of services offered by other ministries and agencies while the richest 20 per cent take more than a quarter of those same resources. In recent decades, the government has reformed and restructured healthcare, developed new insurance systems and ways of offering basic health services. The administration of government health services has been decentralised to make it more efficient and equitable. Nevertheless, many of these efforts have had disappointing results. Patients still complain of poor services and low-paid doctors still strain to treat them while state budget drafters continue to grumble about resource shortages and rising health costs.
