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The price of poor healthcare
Published in Al-Ahram Weekly on 05 - 04 - 2016

Last month, thousands of Egyptian doctors protested against alleged police abuses after a reported 28 January assault on two doctors at Cairo's Matariya Hospital. The incident reportedly took place after a police officer was told that the cut on his forehead did not require stitches, after which the doctors were allegedly beaten up by the policemen and one officer pulled out his gun and threatened other hospital staff.
Two weeks after the widely reported assault the policemen were held on charges of violence but were later released on bail with the guarantee that they would keep their jobs. Well beyond the issue of violence in some state hospitals, the Matariya incident spotlights a wider issue that has to do with Egypt's inadequate public healthcare system, doctors' grievances, and the rights of patients that are often insufficiently safeguarded.
Outside the Imbaba General Hospital in Giza the scene is buzzing. Leaning in front of check-in windows, standing outside the entrance, or simply queuing up or sitting around, many people are waiting to see a doctor. However, they may be there for some time. “The public health service is bad, the minister of health is a failure, and so is the government,” one patient, Gamal Mohamed, complains. “The day our government treats doctors and nurses well, it will treat us patients well too.”
Egypt's Doctors Syndicate held a general assembly on 12 February to address the alleged attack in Matariya, and it also served to highlight many doctors' demands, including the prosecution of the assailants, the protection of hospitals from acts of violence, the drafting of legislation imposing heavy penalties on those who assault doctors, and the resignation of the health minister.
“We are not talking politics, and we are not pursuing anything but our legitimate rights, which mean the protection of the dignity of doctors and the safety of hospitals for all patients and medical workers,” doctor Mona Mina said in an interview with Al-Ahram Weekly.
“Medical staff in public hospitals face many problems, from inadequate training and deficiencies in hospital equipment and medicine to low salaries and a lack of safety,” noted Ahmed Fathi, a young doctor who was at the Matariya Hospital on the day of the assault.
Doctors in Egypt have been unhappy with working conditions and the health system in general for quite some time. Medics often work under a lot of pressure and in challenging conditions characterised by under-staffing, a shortage of drugs and equipment, a lack of hospital beds and poor infection-control standards.
According to World Health Organisation (WHO) information reported by the Website Al-Monitor, the Ministry of Health provides 30 to 35 per cent of medical services in the country. The Ministry of Higher Education covers more than 30 per cent of services through university hospitals, and other ministries, including defence, transport, aviation, electricity and the interior, together with the Health Insurance Organisation (HIO), deliver more than 10 per cent.
Currently, the largest provider of in-patient healthcare services in Egypt, the Ministry of Health, has around 1,048 in-patient facilities accounting for more than 80,000 beds nationwide. By contrast, the private sector has 2,024 in-patient facilities with a total of about 22,647 beds. This accounts for approximately 16 per cent of the total in-patient bed capacity in Egypt.
Based on data from the Health Ministry, in 2014 around 40 per cent of state-run hospitals were unable to provide decent medical services due to ill-maintained equipment and facilities. Public health facilities lack well-trained nursing staff and doctors, and medications are not always available. They are also over-crowded. In 2013, Egypt had an average of 14.88 beds in hospitals for every 10,000 people, and Cairo, which has the highest number, had 34 hospital beds for every 10,000 people, according to the Egyptian Centre for Economic and Social Rights (ECESR), an NGO.
Patient overload is flagrant compared to the available facilities, resulting in endless lines and patients waiting long hours for consultations. Ministry of Health statistics indicate that in 2011 just 643 public hospitals were serving a total population of around 80 million people.
Nurses are unhappy too. Like doctors, they lament poor working conditions, low standards, little security at hospitals and the sometimes desperate state of hospital facilities.
Speaking to Ahram Online in 2012, nurse Sayeda Al-Sayed described the situation for Egyptian nurses as “terrible,” adding that the LE70 ($11) she is paid for a month's work is impossible to live on.
Commenting on a visit to the Helwan General Hospital, Al-Sayed was quoted as saying that “the whole healthcare system is falling apart.”
In order for the country to enjoy a reasonable healthcare service, “we need well-trained doctors, well-equipped hospitals, and national legislation regulating the medical profession and healthcare,” said George Nashed, a professor of surgery at Cairo University, who said that overall the medical care in Egypt was still “fair”
REFORM PRIORITIES: Nashed said that certain areas should be seen as priorities for reform. Decreasing the number of students accepted in medical schools would help prepare better quality medical graduates, he said.
Implementing a training system for medical staff that is standardised nation-wide would ensure junior doctors to be well-trained. Raising the share of state expenditure for healthcare would equip hospitals with appropriate equipment to serve patients. In Nashed's view, the new health insurance law is a first step towards an up-to-standard healthcare system.
The law is set to establish a social health insurance system by requiring all citizens to pay monthly subscriptions. The government is said to be entering into contracts with private and public hospitals alike based on quality standards which critics say will play in the private hospitals' favour. Given the worsening quality of services in the public healthcare sector, the Doctors Syndicate fears that public hospitals could be excluded from the new health insurance system.
The syndicate has called for amendments to the proposed health insurance bill, which was issued in January, voicing concerns that it could eventually contribute to the privatisation of the state medical sector. The current health insurance system covers just 52 per cent of the population. The Ministry of Health says that as a result of the new bill the health insurance system will cover all Egyptians.
With such major challenges facing the medical profession in the pipeline, doctors are reflecting on the services delivered to patients. Fathi noted that many times patients do not see what underlies the under-performance of medical workers, commonly leading to misunderstandings. As front-line staff, doctors and nurses are closest to patients, and they can be exposed to threats or even attacks by angry patients and their families frustrated by inadequate health services.
“If a doctor in a hospital cannot adequately treat a patient because he cannot order the right scans or provide the necessary medication, this is not negligence on his part. It is not the fault of the doctor if he is denied a state-subsidised fellowship and is forced to pursue one at high cost in a private university that later sends graduate students to public hospitals,” Mina told the Weekly in February.
Hospital workers sometimes complain of verbal abuse, intimidating behaviour and even physical assaults from patients as a result of the stresses they are under. Medical personnel can also find themselves without protection against mistreatment.
For Nashed, a board member of the syndicate, such incidents are mainly due to insufficient medical supplies, inadequate training for doctors, and the lack of proper legislation to protect hospital staff. He thinks that medical workers should be better trained on how to deal with angry patients and their relatives. He also believes doctors should be safe while performing their medical duties, as much as patients should be treated in safe hospitals.
In spite of the difficulties they have to put up with on the job, many medical staff are under-paid, with monthly salaries as low as LE1,000 forcing many to work extra shifts in private practice to gain more income.
Fathi earns LE2,500 per month, which is hard to live on though as a single man he does not have family responsibilities. “It's not uncommon for a doctor to work two, three, or even four jobs just to be able to live and sustain his family,” he pointed out. “I have colleagues who don't go home for days because they're out working.”
The head of the Doctors Syndicate in Cairo, Sanaa Fouad, who retired five years ago, receives a meagre pension of LE1,500 monthly. Before retirement, she used to earn LE2,500 a month.
Nashed earns a $1,000 monthly salary, which he says is unusual and in any case is still insufficient, however. He also does private consultancy work. In general, Egypt's doctors are allowed to work simultaneously for the government and in the private sector. A large number of private providers are doctors who are employed by the government but also run a private practice. Other physicians may not be able to afford to open their own private clinics, so they work in more than one non-governmental or private facility in addition to their public-sector jobs.
An Egyptian National HealthCare Provider Survey showed that 89 per cent of physicians with private clinics had multiple jobs. 73 per cent had two jobs with another job outside their private clinics, 14 per cent had three jobs, and two per cent had four jobs.
PATIENTS PAY THE PRICE: Patients can pay the price of inefficiencies and worse in the face of a public healthcare service in Egypt that falls short of basic standards. In some cases, the price can be as high as loss of life due to an unavailability of intensive care units (ICU), lack of hygiene or maltreatment.
Shortage of space is one issue physician Mohamed Rabie pointed out to Ahram Online in 2012. The Mansoura International Hospital in the Nile Delta where he was working at the time only had 12 beds in its general ICU, eight in the cardiac ICU, and three in the children's ICU. Rabie said on one occasion that three children had died because they desperately needed to be in the ICU, but all three beds were taken.
Hossam Kamel, an ICU physician at a village hospital in Mansoura, also spoke to Ahram Online, saying that he had often had to transfer patients in critical condition to other hospitals because of a lack of space in the ICU. Kamel revealed that at least half of the patients had been in critical situations while being transferred, and those who survived ended up with serious complications because of delays.
Hygiene in health facilities is another major problem. Health facilities are often not stocked with sufficient quantities of surgery packets, which means these packets are reused and not properly sterilised as they should be. Such negligence can result in patients facing medical complications.
This also explains why Egypt has the world's highest rates of Hepatitis C, accounting for 14.7 per cent of the population. As a result of inadequate infection-control practices and therapies such as blood transfusions, the virus can be easily spread in the health sector. And without treatment to deal with it, Egypt suffers from a high incidence of the disease and a mortality rate of 40,000 dying from Hepatitis C every year.
As millions of Egyptians suffer from the disease, doctors dealing with patients can end up getting infected too, and many patients can die because they don't earn enough to get proper treatment. “I've seen doctors treat HIV patients without gloves and deliver a baby with their bare hands,” said a doctor called Heba at Demerdash Hospital in an interview with Al-Monitor last year.
Poorer people who cannot afford to pay for medical care often have no choice other than to get what's available in the public system. Those who have the financial means tend to rely on private facilities to fulfil their primary healthcare needs, though these are not available to many in a country where half the population lives in poverty and a quarter lives in extreme poverty.
In front of the Mounira General Hospital in downtown Cairo, patients can be seen coming in and out. Two gates smoothly direct the traffic for incoming and outgoing visitors. It doesn't look busy at the entrance, but it gets crowded inside.
“Not everything is available here, and there are lots of medicines I have to pay for,” said patient George Raeda, 61, who had just seen a doctor for his back pain. He is generally satisfied with the service he gets and finds the medical team helpful. But he complained about waiting times that could be up to two hours.
Another patient, diagnosed with cancer, was going to get a biopsy from a private hospital because she couldn't have one done in the state system. A young boy called Abdel-Rahman Ibrahim had come to see his sick father. On his way, he had had to buy the medicines he couldn't find at the hospital. But he seemed happy with the way his father was being treated.
Waving a prescription in her hand, Fatima Abdel-Rahman, 60, said she would have to buy two medicines from outside the hospital. She has arthritis in her knees and pains in her chest. “I have a small income, and my husband is a pensioner, so I can't spend much on medicine,” Fatima said. “When I can't afford to buy medicine, I don't buy it.” However, she said she was pleased with the services provided by the hospital. Before that she had been to a small public clinic where she wasn't examined properly, she said.
Mahmoud Metwalli, 72, has diabetes and suffers from a hearing impairment. He needs a hearing aid that costs about LE2,000. “We won't be able to buy it unless somebody helps us financially,” his wife sighed. She is nevertheless happy with the medical services provided at the hospital.
“People here don't have high expectations. They're satisfied with any little thing they can find that will help them. That doesn't mean everything works well on the other hand,” explained Ahmed Shawki, a doctor working at the hospital.
Some patients like Fay Sawiris, 67, and his wife Nagah are very positive about the public healthcare system. “My husband is going to get his teeth done for free. I get free medicine for my diabetes, and my sister gets medicine for her hair loss. We're very happy,” Nagah said. As a retired civil servant, Fay used to go to the Moqattam Hospital under his health insurance. However, he opted out after realising he was getting bad treatment, even though he now has to cover some medical expenses himself.
In February, many doctors in Egypt began a free healthcare campaign, which aimed to provide medical services free of charge at public hospitals. It is to remain in effect until the Doctors Syndicate's next general assembly. The initiative came one week after medics staged a series of silent protests across the country following the alleged police aggression in Matariya.
The Mounira Hospital is among the public facilities that has taken part in the campaign. “I usually have to pay for my x-rays, but this time I didn't,” Fatima said, delighted. “A public hospital should always provide free treatment, as most people coming here are on low incomes.” Some doctors in private practice also showed their solidarity by offering one day of free check-ups on Egypt's National Doctors Day, which falls on 19 March.
Outside the Imbaba General Hospital and accompanied by her husband, Sabah Mohamed, 50, comes regularly to see a doctor about the rash on her leg. “It's very crowded, but I don't have to wait for long,” she commented. “The service is good and free,” she said. Gamal Mohamed, 49, on the other hand, sounded less happy. He is given drugs for his diabetes that get changed every few months depending on what is in stock at the Hospital. This could mean being dispensed a less suitable medication.
“The smallest thing you ask for at the reception, you will be turned away and told to get it outside,” he said angrily. “They're trading with people's health.” Gamal works on a day-by-day basis. Taking a 25 piastre coin out of his pocket, he said this was all he had left to live on that day. He said he would have to walk all the way back to the Faisal neighbourhood to reach his home. He also needed to have a tooth replaced, but he could not afford the LE1,000 it would cost.
Sitting with a three-month-old baby in her arms, Mona Ibrahim, 24, waits quietly. Her child has an allergy. Every week, she has to buy medication costing LE30-40, which is expensive since she has other children to look after. Another hospital didn't have milk to dispense for her son, she said, so she had come here instead.
Walking out of the hospital, 45-year-old Muammar Gaddafi and his wife do not hide the discontent on their faces. After being referred to two other hospitals to get his teeth fixed, Gaddafi had come to the Imbaba Hospital only to be told that he would have to wait until May to be treated. “The doctors and nurses do what they can,” Gaddafi pointed out. “But they don't have the equipment and facilities to treat patients.”
“I usually don't go to public hospitals,” he added. “Nobody cares about you, the medical treatment is not good, and you still need to buy medicines out of your own pocket because the drugs you find inside the hospitals are less effective.”
Gaddafi's wife had come to the Imbaba Hospital several times for her mother who had partially lost her sight after eye surgery done at another public clinic. “This hospital doesn't have the equipment to fix my mother's eyes. I don't have the money to take her to a private clinic, so I just come here to get her eye drops,” she complained. “And look how over-crowded this place is and how long we have to wait.”
DECLINING SERVICES: “Have you seen any good public hospital in Egypt? Or a hospital where a patient can get good treatment,” asks Fouad. She thinks the country's healthcare system should be restructured altogether such that hospitals can reach international standards, especially in terms of the level of quality provided to patients.
“Doctors cannot do their jobs properly at the moment, and patients don't get what they need,” the Cairo Doctors Syndicate chief stressed. “The government has to put patients' rights at the top of its list of priorities.” Egypt's doctors and patients have long lamented critical deficiencies in the system, like shortages of medical supplies, scarcity of intensive care units, inadequate medicines, and a shortage in well-trained staff at state-run hospitals.
The system has also been declining over the last three decades of budgetary constraints.
Increases in the healthcare budget have for many years been the key demand of those who want to see a more even distribution of funds, better doctors' salaries, improved medical facilities and better hospital security. Egypt allocated just 1.7 per cent of GDP to the health sector in the 2014-15 budget, according to WHO figures. This is clearly below the three per cent minimum stipulated in the 2014 Constitution. Many countries spend an average of 15 per cent of the national budget on healthcare.
On the other hand, out-of-pocket spending on healthcare can be very high in Egypt, amounting to 72 per cent according to the World Bank. Many Egyptian families are burdened by these costs, especially when it comes to purchasing medication. It is unsurprising that such an under-funded healthcare service does not adequately respond to the demands of the majority of people, and the poor state of public hospitals in Egypt has been worsening over recent years.
Last summer, the local media reported several horror stories about negligence in the public healthcare sector. In June 2015, a Facebook campaign circulated pictures exposing dire hospital conditions, sharing shocking images of stray cats and owls inside run-down state hospitals, damaged bathrooms, hazardous waste and even snakes inside wards.
Egypt's decaying healthcare system also doesn't match with the basic rights guaranteed by domestic laws and article 18 of the Constitution. This says that “every citizen has the right to health and to comprehensive healthcare that complies with quality standards. The state shall maintain and support public healthcare facilities and shall enhance their efficiency and their equitable geographical distribution.”

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