At the southern end of Qasr Al-Aini Street in Cairo, the famous hospital of the same name is still there in all its former glory, at least in appearance. The massive gates speak of past prestige, but the tell-tale look of resignation on the faces of outpatients speaks of suffering that medical conditions alone do not necessarily bring to the faces of patients. The hospital is a crowded place, and according to some of its patients not the kindest. At 9:30am, the hospital's outpatient clinic is already buzzing with patients. In corridor after corridor, between buildings, and in front of check-in windows, they line up patiently, take a number, and wait their turn. Some of them rest on seats the hospital has provided in the spaces between the buildings. But there aren't enough seats for all. So many stand up, leaning on the walls. Some wile away the time buying overpriced biscuits and drinks from a table nearby. A captive audience, they pay grudgingly for the edibles, sold at mark ups of 25 or even 50 per cent of those elsewhere. One old man leaning on a crutch is eating a piece of bread, perhaps bought on the way to save money. He asks a patient standing nearby what his number is. “63” comes the answer. Both know a long wait is ahead. A diabetic patient complains that his feet can no longer carry him. He says the doctor doesn't seem to care. The doctor has refused to give him a slip to get medicine that costs LE10 ($1.25), he says. Moment later, those about him rush to support him, just in time, as it turns out, as he has fainted. The oldest hospital in Egypt, the Qasr Al-Aini Hospital is a haven for the poor and needy. But patient satisfaction is low, lines are long, and doctors are underpaid. For the past two years, Egypt has come last in healthcare in the World Economic Forum's Global Competitiveness Report. This is hardly surprising as the local media have long been filled with horror stories about negligence in public and private hospitals and clinics in Egypt. The problems started in the mid-1970s, according to Mohamed Khalil, a key figure in the Right to Health Initiative, a non-profit group campaigning for better healthcare in Egypt. Starting in 1974, the government started spending less on preventive medicine. Medical trucks used to visit distant areas to provide preventive treatment for common diseases, allowing the residents of the southern governorates in particular to receive care for common diseases such as eye infections. But then the convoys stopped, and blindness increased in Upper Egypt, making it one of the worst-hit regions in the world in terms of eye diseases, Khalil said. Budget constraints have taken their toll on the health sector since. But hopes were revived for more funding when under pressure from civil society groups the constitution was amended to set aside further spending on health. Article 18 of the Constitution now requires the government to spend a minimum of 10 per cent of GNP on health, education and scientific research. To comply with this article, the government still has to increase its health-related expenditure to about three per cent of GNP, though this hasn't happened yet. Last year, the government spent 1.6 per cent of GNP on health. This year, the percentage dropped to 1.5 per cent.
NOT ENOUGH DOCTORS: Last year, Egypt's budget deficit was 11.5 per cent, forcing the government to reduce spending on health, says Ministry of Health financial adviser Mohamed Moeit. Inadequate spending leads to shortages across the board. According to Khalil, Egypt has 1.2 hospital beds per 1,000 patients, 1.2 nurses per 1,000 people and 1.1 doctors per 1,000 people. According to Moeit, the country needs to triple or quadruple these figures to comply with international standards. Egypt has no shortage of medical school graduates, yet the country has a shortage of doctors because young doctors prefer to work abroad where the pay and working conditions are better. In Saudi Arabia, for example, Egyptian doctors outnumber Saudi ones, prompting the Saudi health minister to joke that he is “Egypt's health minister,” not Saudi Arabia's. The Egyptian Doctors Syndicate, trying to redress this situation, has called for a six-fold increase in pay for doctors, a request that the government is trying to meet. Since a new salary scheme for doctors was introduced in January 2015, doctors' pay has risen by 450 per cent. But since salaries were very low to start with, the increase has only meant that new graduates are taking home an extra LE500 ($60) or so a month. Another problem is professional hazards. When a female doctor, Dalia Mehriz, died in Ismailia recently after catching meningitis in the course of her work, the syndicate demanded extra pay and medical care for doctors exposed to hazardous situations. While activists such as Khalil argue that low spending is the main problem for the health sector in Egypt, ministry officials point to administrative complications. For example, Moeit says that the health sector is run by numerous agencies, some central and some provincial, preventing coordination. “This impedes the formulation of comprehensive plans,” he said, adding that eight agencies are in charge of health services in the country. These include the Directorate of Hospitals, the Health Insurance Department and the local Health Directorates. While hospitals are run by the governorates, the directorates are controlled by the ministry in Cairo. Turf issues and a lack of coordination give rise to a host of problems. The solution, according to Moeit, is to bring all these entities under one administration. For decades, successive governorates have also tried to put together a comprehensive health insurance scheme for the country as a whole, but a decent programme for healthcare in Egypt would cost money the government doesn't have. In August 2015, Tarek Al-Ghazali Harb, a member of a panel trying to put together a health insurance scheme for all, told journalists that the committee was “no longer meeting” on a regular basis. It had not been disbanded, he said, but it couldn't move forward in the absence of funds to back its proposals. According to Harb, a comprehensive health insurance scheme in Egypt would cost a minimum of LE80 billion ($10 billion). Khalil is one of the activists supporting the government plan for a comprehensive healthcare system. But his concern is that the scheme as originally formulated would have involved a level of privatisation that would have burdened the poor. If the scheme had been approved as put forward, Khalil said, it would have allowed for the privatisation of the healthcare sector, which would have driven up costs for poor people. Under the current health insurance system, the government is committed, at least in theory, to offer treatment for all conditions without exception. In return, beneficiaries of the system are expected to pay a flat membership rate, regardless of their medical conditions or the type of treatment they receive. The proposed changes in the health insurance system, which Khalil is resisting, would have excluded some diseases and part of the cost from the insurance scheme. This would have compromised the interests of the poor, he says. In April 2013, the Egyptian Initiative for Personal Rights (EIPR), an NGO, produced a research paper on the proposed health insurance law. According to the paper, the Ahmed Nazif government (2004-2011) made a bid to refurbish the health sector, but couldn't push it through due to inadequate funding. At present, government spending accounts for only 28 per cent of total spending on health. The rest, 72 per cent, is what Egyptian families pay out of their own pockets. If the health insurance system is amended, the percentages may change, with families paying even more than before, activists say. The last time a panel of experts discussed amendments to the health insurance system in Egypt, the proposals it made would have allowed the government to share the cost with beneficiaries. About one-quarter of subscribers would have had full coverage, while the rest would have had to pay up to 20 per cent of the cost of their treatment. This would seem to be a reasonable compromise, but activists say it would still be unfair to the public. And the government says the cost is still too high. Ministry of Health spokesman Hossam Abdel-Ghaffar says the government now intends to implement a different plan. The first stage of this, put into effect in the first half of 2015, covered 12 governorates, and the second stage, ending in March 2016, will cover 15. According to Abdel-Ghaffar, 487,000 families, or 2.4 million people, are now covered by the new health insurance plan. Once complete, the new scheme will cover about 23 million people, or 26 per cent of the entire population, and will take four years to implement. Beneficiaries will be supplied with smart cards to keep track of their coverage costs. Even the unemployed and day labourers will be covered by the new scheme, Abdel-Ghaffar said. But whether the new scheme will gain the approval of activists, and whether the government will be able to afford it, still remains to be seen.
