Everyone agrees the health system is falling apart. What arouses controversy is the government's prescription for reform, writes Hala Sakr The first National Egyptian Conference on the Right to Health convened at the Press Syndicate on 2 October, bringing together 50 political parties, syndicates, unions and civil society organisations to declare their position towards the health insurance law, due to be presented to parliament during its next session. Gamal Fahmy, Press Syndicate council member, opened the conference, stressing the meeting was part of a collective battle to defend a range of rights, including freedom of the press, currently under attack. The conference was chaired by Alaa Shukrallah, head of the Association of Health and Environmental Development (AHED), who emphasised that the gathering was not intended to discuss or scrutinise the law. "We are here to declare a unified stand and make clear demands that will mark the beginning of a collective effort to formulate an alternative to the proposed law," said Shukrallah. "We want to show the government and the world that there is opposition to this law which was drafted in secret and without any transparency." Shukrallah, together with other health activists opposing the law, sees the conference as a culmination of work over the past two years, including that of the Egyptian National Right to Health Committee, in defence of people's right to access healthcare services. The committee was set up in April this year in response to Prime Ministerial Decree No. 637, issued a month earlier, which established a holding company for the Health Insurance Organisation (HIO). In a brief presentation Mohamed Hassan Khalil, consultant cardiologist at Nasr City Health Insurance Hospital and a vocal opponent of the decree, argued that it was the first step towards privatising the health sector. "[The decree] transformed a non-profit-based service into a profit seeking one. It stripped the HIO of all its assets and transferred them to a profit-oriented holding company which has the right to sell these assets. The next step is the current draft law." Khalil pointed to "a number of detrimental aspects in the law". It attempts to impose different service packages with different premiums which will move the basis of health provision to people's means rather than their needs. It also gives the minister of health and prime minister the prerogative of changing the contractual relations between the HIO and its clients when this should be the subject of a clear and regulated legal process. The new law also fixes patients' contributions as a percentage of service fees, and at a level that is beyond the reach of a majority of the population. Both the government and its opponents agree that the health system has deteriorated to such an extent that a radical overhaul is now essential. What separates them is the direction the needed reforms should take. Samir Fayyad, of the Tagammu Party, points out that alternative approaches to reform are available. "The dilemma is that attitudes to health reform cannot be separated from the wider political approach. We are against the market economy, particularly when it comes to health. Health is not a commodity. Health provision must always be subject to social scrutiny." The drafting of the new law is informed by the questionable orthodoxy that public service provision is automatically hampered by being run by the government. The answer posited by the law is to separate the funding and provision of services, with the latter subject to market forces and incentives. But deteriorating healthcare provision, as Shukrallah points out, has many causes. "We differ drastically [with the government] about why this has happened and how it can be fixed." One reason for the deterioration, he argues, "is the declining support of the government to public facilities since the mid-1970s, a policy approved by the government and propagated by international agencies such as USAID and, later, the World Bank. This declining support hindered, and even corrupted, provision through the introduction of privately run services within the public sector." "This law will increase inequality by placing many health services out of the reach of the vast majority of Egyptians," Shukrallah told Al-Ahram Weekly. "What is at stake is the right to access health services. Services can be improved by organised supervision rather than through competition." The conference's rejection of the new law in its current form was unequivocal: "in its current form it is non-constitutional... it runs counter the equal right of citizens to appropriate healthcare and... goes against human rights conventions and treaties to which Egypt is a signatory." A statement by the Association of Human Right Advocates distributed at the conference argues that the new law also violates the International Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights and the Egyptian constitution which, in articles 16 and 17, stipulates that "the state shall guarantee... health services and shall work to ensure them," and in Article 17 that "the state shall guarantee... health insurance services." Mohamed Zahran, head of the Wafd Party's Health Committee, says that while "the goals of the law as stated by the government are ambitious -- universal coverage and service improvement -- it has failed to protect the interests of the people, particularly the less privileged." "The proposed law," he told the Weekly, "has raised concern across the Egyptian political spectrum, even within the ruling party itself." Abdel-Gelil Mustafa, professor of medicine and a member of the 9 March movement, believes that what the new law promotes is a flagrant commercialisation of healthcare. "There is always room to reach consensual and feasible solutions. But dilemmas arise when solutions are dictated by hegemonic powers. When that happens we are as far as can be from the most appropriate solutions to specific problems." The conference's final declaration made the position of participants clear: "... we totally reject the introduction of the law in the coming parliamentary rounds... it was developed over two years without transparency... we demand that no changes be introduced without proper consultation. We propose a national dialogue during the coming year through which alternatives can be developed through dialogue with political parties, syndicates and unions and other civil society organisations."
