Living dangerously

With a glut of doctors and the dream of universal health care coverage, why are so many people left to fend for themselves? Hala Sakr sizes up the task of health care reform
(top) on the operating table: does the health system have a chance?; (left) what choice does a low income patient have?
photos: Sherif Sonbol
The term "public hospital" in Egypt usually evokes grave nods of the head and the inevitable reference to a popular saying: "Those who enter are lost; those who leave on their feet are re-born." So it was with fair forewarning that I headed over to 6 October Hospital in Doqqi. At the entrance, I was struck by the building's obviously expensive and lavish decoration -- marble stairs, marble walls, the hospital's name gleaming in polished brass. A handsome security guard in a blue uniform dutifully directed me to the out-patient clinic on the back street.
The back entrance was not so glamorous. A steady stream of people were pushing their way in and out of the gloomy building and a large sign confirmed the spot: Emergency Medical Service, 24 hours. I plunged into the throng and entered the hospital. People who are covered under the government's health care system are required to register when they enter, but since I do not qualify as a beneficiary, I was directed to buy an entrance ticket. "You should check whether the internal medicine clinic is open today," the clerk warned. So much for 24 hours.
Picking my way through the clinic's corridors, I asked nurse after nurse for assistance until one finally told me to "ask Dr Mamdouh." Perched strategically behind his desk, Dr Mamdouh refused to examine me. I tried the door next to his in search of a willing doctor, only to find it empty. On my third try I glimpsed a doctor through a half-open door. "Stop pestering me," he barked. "I will only see diabetes cases today!"
On my way out of the hospital I noticed a billboard with a memo tacked on it announcing to all concerned that any doctor, nurse or personnel working at the out-patient clinic who did not provide the public with the finest service and treat them politely and with respect were subject to strict punitive measures. The notice was signed by the Health Insurance Organisation (HIO). A few paces away sat an old woman, her leg in a cast, crying. "Five days ago I came in with a broken leg," she sobbed. "They put it in a cast, but refused to give me my diabetes medication in the same visit. I had to come for it today. So I did, and the doctor will not see me."
It seems that everyone has a story to tell. Ahmed, the parking attendant working the street before the hospital was in for a shock when he broke his leg playing football. "I went into the hospital's emergency department," he recounted. "Most of the doctors know me, because I take care of their cars. But they kept on shooing me from one doctor to the next until I was forced to go to a non-insurance hospital, where I was finally treated. This is what happens when you fall into the clutches of the system -- everyone turns their back on you," he growled.
The current health insurance system is a product of the 1960s, when populist policies were developed to eventually extend basic services to all citizens. The 1962 Charter stipulated that everyone should be covered by health insurance, but failed to delineate a concrete plan for implementing this and gave no schedule or deadline for accomplishing the task. In 1964, the HIO was set up to provide compulsory health insurance for workers in the public sector. The service was then to be extended to the entire population, but despite the numerous expansions that have taken place, the HIO still only covers 55 per cent of Egyptians.
And, naturally, it is not only the scope of coverage that is the problem; the lack of quality service has become undeniable. "The inefficiency of the present system is the main factor creating an urgent need for a new, more competent and updated alternative," Hamdi El-Sayed, head of the Doctors Syndicate and parliament's health and environmental affairs committee, told Al-Ahram Weekly. The cost of medical care has escalated dramatically, El-Sayed noted, and it will only grow more expensive with the implementation of General Agreement on Tariffs and Trade (GATT) in 2005. "Today we are confronted not only with poor-quality service, but also a gross financial deficit."
Samir Fayyad, a consultant to the Egypt 2020 project -- run by the non-governmental research institution the Third World Forum -- put it more bluntly: "Currently, people do not use HIO facilities because they fear they will be in danger from negligence or forced to suffer unnecessarily protracted procedures."
The only hope is health care reform -- in itself a convoluted endeavour. A new draft law dealing with national health insurance addresses the need for streamlining health care procedures and aims high: universal coverage in five years. The bill -- the product of elaborate coordinated research by the Ministry of Health (MOH), the Doctors Syndicate and the parliamentary health committee -- was presented to the complaints and proposals committee in parliament and has already received approval in principle.
The new legislation separates financial, managerial and auditing tasks so that they no longer clog up the bodies charged with providing health care service. It also specifies the provision of additional funds over and above the premiums paid by the beneficiaries of health insurance. Proponents of the bill claim that by utilising all the health facilities available, we can begin to expand health care coverage to more people, starting with governorates that already have sufficient medical facilities. Over the next five years, medical systems and resources in other governorates would be adjusted to accommodate the new setup.
Not surprisingly, the bill has its detractors and has generated some heated debate as to the means, schedule and priorities of upgrading health care services. "If we expand an already deteriorating health insurance system, the results will be catastrophic," argued Nabil El-Meheiry, a professor of surgery at Ain Shams University and former head of the HIO. "It can only mean an overall dissemination of poor quality medical service," he said, noting that at the very least, a 10-year programme of reform would first need to be implemented that would improve the existing system and prepare it for more radical change.
Before a law like this is passed, Fayyad argues, it should have the backing of a wider range of professionals and should be the subject of extensive debate and recommendations from scholars, health care providers and the people most often left out of the decision-making process: those who use the services. "If providers and users are in conflict over the reality of current health services, an independent field survey should be carried out," Fayyad suggested. "The results should then be put forward for debate."
But debate, it seems, is exactly what health care bureaucrats fear most. "The HIO works in complete discretion," Fayyad said. "I challenge anybody to access documented information of any kind through the system." The Weekly took Fayyad up on his challenge, but failed miserably. "Health reform is a complex, interactive and purposeful process, which should consider the existing political, social, economic and institutional realities," Fayyad argued, adding that the freedom to debate these issues is in the benefit of both users and providers, while transparency helps providers to recognise and correct flaws in the system.
Health services are provided through the governmental sector, the public sector and the private sector, which adds up to an unruly labyrinth of channels facing the average health care seeker. Ministry of Health organisations include the Central Labs, the Central Vaccine Organisation and the Drug Control Organisation, as well as the rural and urban health delivery systems in different governorates. Public sector organisations include the HIO, the Teaching Hospitals and Institutes Organisation and the Curative Care Organisation. University hospitals come under the umbrella of the Ministry of Education, while other governmental bodies -- the Ministry of Defence, the Interior Ministry, the Prisons Authority, the Railway Authority, to name just a few -- all own and control their own medical institutions. The only instrument that oversees and reins in these myriad facilities and organisations is the law governing medical practice in general.
Under the new legislation, this would change. The HIO would become a para-governmental body, both administratively and financially independent. The organisation's board would bring together representatives from various sectors, including the private sector and workers, and be chaired by the minister of health. Doctors Syndicate head Hamdi El-Sayed is quick to point out that the presence of the minister at the top of the hierarchy should not provoke concerns about the organisation's independence. "[The HIO] is run by a whole board, whose members represent all the parties involved. But at the end of the day, there must be an authority that assumes responsibility for the health care system as a whole -- the Ministry of Health," El-Sayed said.
The core of the new system, according to El-Sayed, is "managed care", which he describes as being based on "modern management techniques and competition as a means towards quality and cost effectiveness." The HIO would have both direct and indirect resources to fund its programmes. "Direct" income comes from the premiums and co-payments paid by beneficiaries, as well as contributions from the state treasury. "Indirect" funds would come from taxes levied on particular industries and goods that are considered hazardous to the health, such as cigarettes and alcohol, sugar and insecticides.
Egypt currently spends an estimated LE11.5 billion on medical care, roughly 4.7 per cent of gross domestic product (GDP); the international average is 7.4 per cent of GDP. Grants are mainly channelled into the governmental sector, with about 70 per cent going to the MOH and the rest to university hospitals, teaching hospitals, NGOs and private clinics. Funds are also raised from employers who use social insurance.
In the 1990s, 58 per cent of Egypt's total health care expenditure came from households and firms (out-of-pocket spending), which amounts to about LE180 per capita annually. The out-of-pocket share in developed countries is 30 per cent. In contrast, most developing countries depend on out-of-pocket spending to fill in more than 50 per cent of the total health care expenditure.
Though daunting, most experts believe streamlining health care expenditure is feasible. "Canadian health expenditure is almost half that of the USA, yet they have managed to set a model regarding quality of service and client satisfaction that is on par with the American system," notes Third World Forum consultant Fayyad. "The target remains to reach the international average for health care expenditure. For this, reallocation of resources between all sectors as a whole, particularly health, is mandatory."
The current budget of the HIO is LE2 billion, a third of which is spent on drugs from private pharmacies. Another third goes towards treating national health care beneficiaries in institutions contracted by the HIO. The rest is used to finance the HIO facilities, including units owned by the organisation itself and those leased from MOH. The problem is, the selection of such units is arbitrary. "[The selection] follows no rule," claims Fayyad, "but simply follows the orders from above -- or personal inclinations. Rules should be clearly stated. The HIO, as a stronger party, should enforce a system of selection that produces the best quality service available for the least cost."
Fayyad argues that rather than seek efficiency, the HIO sacrifices quality for the sake of taking in the large numbers of physicians who graduate from medical schools every year. "If these doctors spend seven years at medical school, why is it so hard to get them to spend a few more years on a general practitioner's degree?" Fayyad asks. "It is not only useful in educational terms, but also in terms of practical training and improving skills."
According to figures from the Ministry of Health, the ratio of doctors to the population is 2.1 per 1,000 people. In the UK, the ratio is 1.4 doctors per 1,000 people. The MOH, with its limited financial resources, employs about half of the total number of physicians in Egypt. Consequently, the basic salary (before added-on incentives and bonuses) of the average physician is low: LE120 per month when first appointed, rising to LE600 at the time of retirement. Most physicians end up taking on more than one job, which explains why doctors are concentrated in major cities, rather than being evenly distributed throughout the country.
On the point of salary, former HIO head Nabil El-Meheiry is adamant. The key to reform, he says, is full-time jobs for physicians with adequate remuneration. "In Egypt, billions of pounds are spent on health annually. The syndicate should fight for a decent minimum salary for all physicians. After all, why should one university hospital hold eight units for haematemesis [vomiting of blood originating from the upper part of the digestive system] when one is more than sufficient? The point is, the money is there. The reallocation of available resources is what it will take to make it work."
El-Meheiry recounts his own experience as an example. "When I first came to the HIO, there was a hospital in Kafr Al-Sheikh with only 10 per cent occupancy at the most. They had no competent physicians. I assigned full-time qualified PhD and FRCS physicians from Cairo at a monthly salary of LE5,000," El-Meheiry recalls. "Full time" meant the doctor had to be available from 9.00a.m. to 5.00p.m. five days a week, with two night shifts. The doctors treated health insurance beneficiaries for free, but, crucially, retaining the right to admit private (paying) patients into the same hospital, which El-Meheiry explains fostered a sense of loyalty to the institution. "A year later, the occupancy rate exceeded 75 per cent," El-Meheiry says with satisfaction. "The LE5,000 salaries were accounted for within the existing financial framework of the HIO, with no extra burden. What happened was that the budget deficit narrowed to a noticeable extent. It was no miracle." Despite the alleged success of his experiment, it soon came to an end when El-Meheiry left the HIO.
Because hospitals are over-staffed, El-Meheiry said, physicians have a slimmer chance of practising their skills. To be appointed where they are needed not only gives them the opportunity to improve their capabilities, but to pass their knowledge on to the younger generation. When El-Meheiry took over the HIO he discovered, for instance, that at the gynaecology and obstetrics department at Nasr City Health Insurance Hospital, there were 30 beds to 30 resident doctors and 12 consultants. "How can anybody treat, or be treated, within such a context?" he scoffed. "So long as all these things -- necessary training, a continuous learning process, decent remuneration -- are lacking, who can judge or condemn physicians for the state of health care in Egypt today?"
In theory, the benefit package of the HIO is both curative and preventive. It provides unlimited curative services ranging from those of a general practitioner to overseas treatment for all beneficiaries, irrespective of the cost. "Economically, the HIO cannot support the whole spectrum of medical conditions equally. It has to decide on its priorities and a more defined package of services. If one beneficiary wishes to venture into in vitro fertilisation how would that fit into the existing framework?" El-Meheiry remarked, suggesting that a special programme should be set up for such conditions. "For high-prevalence conditions, such as renal failure, a special fund needs to be established with contributions from the HIO, the MOH and donors, as well as health care premiums. This fund should be concerned with prevention and research as much as it is with treatment."
It is too easy to blame a single authority for the health situation in the country, however, according to Fayyad. "Many variables, such as environmental conditions, style of life, poverty, ignorance and poor housing are all factors which cause ill health."
El-Sayed, nevertheless, is optimistic. "The ultimate goal is an efficient, affordable and accessible medical care system that does not discriminate between people geographically or socially or otherwise." Everyone would agree, but the question remains: how? According to El-Meheiry, the HIO should emerge in a new form with a new outlook -- total independence with a strong board of health economists, insurance specialists and hospital owners to promote new concepts and attitudes. It should have the right to develop its own administrative and financial system, without any interference from the Ministry of Finance. "All this is not feasible without an overall system that observes transparency and democracy," El-Meheiry added.
For the average person, adequate health care reform couldn't come soon enough. Yet among this legion of physicians are many a doctor, nurse and administrator making what they can of the current system, fighting their way through the tough spots. "In their old age, these people will look back and wonder whether they made a difference," concluded El-Meheiry. "It is their efforts that keep Egypt going."
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