Free-of-charge healthcare: Constitutional right forbidden by government

Only half of public hospitals started enforcing syndicate assembly decision under governmental, administrative threats

Nearly a month has passed since the infamous assault on the Matariya Teaching Hospital doctors by low-ranking policemen. The policemen are still walking free, while doctors have resumed work – with the additional burden of providing free-of-charge medical care without government support.
The assault sparked outrage among doctors across hospitals nationwide. Thousands gathered in a general assembly held at the Doctors Syndicate in mid-February and voted on a set of decisions, including providing free healthcare for further examinations and medications, with the exception of the fee for the mandatory ticket paid for initial check-ups.
As soon as the decision came into effect, conflicts emerged between the Ministry of Health, hospital administrations, and the Doctors Syndicate over the legality of the decision and practical risks of implementing it.
Daily News Egypt visited a group of public hospitals that are included in the plan to implement the decision, where major discrepancies were discovered regarding the rates at which the free healthcare plan is implemented, due to administrative threats.
The sizeable Matariya Teaching Hospital is a vital healthcare facility for patients, not only for those who live in the Matariya suburb but also for citizens in other nearby neighbourhoods. Hundreds visit the clinics every day, while the hospital is still struggling to fully implement the syndicate's decision. It is an educational hospital that falls under the supervision of the Teaching Hospitals Authority.
Momen Abdelazeem, a maxillofacial surgeon at the hospital and one of the doctors who were subject to the assault, told Daily News Egypt that implementing this decision is an uphill battle.
"Anyone working in the hospital other than doctors is against us," he said. "Those who give the check-up tickets or those who do the x-rays are all technicians and they need their share from the money from the patients."
According to Abdelazeem, the total revenues from examinations conducted in the maxillofacial department alone can reach up to EGP 20,000 each day. However none of those funds are given to doctors. "We get our salaries two months later than its scheduled date," he said.
Matariya doctors have moreover been confronted by their managers since they initiated the decision, according to Abdelazeem. "If you did not back off we will fire you." Those were the managers' exact words, according to Abdelazeem.
Painfully aware of the burden of hospital expenses on patients, Abdelazeem no longer wishes to work in the hospital. "I am considering taking an unpaid vacation indefinitely. I am biting off more than I can chew, not to mention the fact that no actions were taken in my assault case until now and everyone wants me to behave normally."
The situation is less severe in other hospitals supervised directly by the Ministry of Health. In Al-Mounira hospital, all medical personnel began implementing the decision. However they are wary of speaking publicly about it, since the ministry has sent a warning letter to the hospital administration to halt the decision.
Two doctors working in the rheumatoid and ophthalmology clinics, who requested to remain anonymous, told Daily News Egypt the reason this decision is being successfully implemented at Al-Mounira is the doctors' persistence.
"All doctors here stood up for the decision to refuse to perform any paid examinations and also criticised doctors who did," one of the doctors said.
On the other hand, they said the decision increased the demand on clinics. "Some patients started coming for regular checkups, such as eyesight examinations – never mind the number of emergencies," one of the doctors said.
The crowding only intensifies as one approaches the examination labs. Patients wait in small rooms and outside rooms for their turn. Many of them confirmed to Daily News Egypt that they did not pay extra fees for the examinations they were about to undergo.
Those two hospitals are among the half of the total 514 public hospitals in Egypt that started implementing the decision, according to the syndicate census.
The decision does not include teaching hospitals, such as Qasr Al-Eini, although it is one of the largest healthcare facilities in Egypt. Many of its medical personnel are not even aware of the decision. The hospital however operates under similarly dire conditions as those in other public hospitals.
In the corridor of its emergency clinics, massive crowds are seen waiting outside, on the benches and on the floor, desperately waiting for nurses to call their names next. Scuffles and loud voices are also heard clearly from inside the clinics, yet no one reacts.
Zeinab M, a senior woman in traditional rural attire, was sitting one of the benches in front of the physiotherapy clinic waiting for her sick daughter. She accompanies her daughter to the clinic three times per week.
Her daughter, who recently underwent an operation on one of her arms, has been suffering nerve pain for nearly four years, but struggled to find the medical specialists who can improve her condition at any of the hospitals near her neighbourhood in Helwan.
"Many recommended Qasr Al-Eini, as it has the specialisation she needs, but the hospital required EGP 5,500 to perform the operation," Zeinab said.
Patients crowd at the check up ticket windows of Matariya hospital, a month after the infamous assault
(Photo by Ahmed Hendawy )
After several negotiations with the medical staff, she said they reduced the fees to EGP 3,500, which barely covers the operation costs. According to Zeinab, her daughter still needs further MRI examination and physiotherapy sessions that she cannot afford; not only because of the hospital's prices but also because of the hospital's distance from their home.
If the hospital decided to implement the free-of-charge medical treatment decision, demand will definitely increase; it will be out of control, said the head of the ophthalmology clinic. "Everything here has become costly. Patients pay all expenses for their medical treatment. Even the family's visitation fees increased from EGP 5 to EGP 10," she said.
Constitutional right or legal violation?
The subsidised – or what is known as free-of-charge – medical treatment has a long legislative history in Egypt; however enforcing it is currently considered a luxury that the majority of public hospitals cannot afford, due to increasingly low budgets, manpower, and ailing equipment.
The reason this decision is highly prioritised nowadays, according to Doctors Syndicate board member Ehab Al-Taher, is the increase of assaults against doctors.
"The healthcare ecosystem has a lot to do with assaults against doctors," he told Daily News Egypt. "When patients find inadequate services, yet they are required to pay large amounts of money, their frustration is directed at doctors; rather than those responsible for the hospitals budget," he added.
The Assiut Hospital director was referred by the health ministry to investigations for implementing the decision on the first week of the campaign, whereas other doctors in Daqahleya were referred to the disciplinary committee at the syndicate for not implementing the decision.
Former prime minister Ibrahim Mehleb issued decision 1063/2014, based on the 2014 constitution, which guarantees free of charge medical treatment during the first 48 hours for emergency cases. The decision also priced medical examinations during the official working hours at only EGP 1.
"It is bizarre how the health ministry is violating the law by threatening those who abide by it," Al-Taher said. Regarding the decision's consequence, which is the increased influx of patients, Al-Taher said: "We accept this burden for the sake of the patients; despite all administrative threats as well."
"At the end of the day, it is a societal battle. People should be aware of their right to access this service for free and speak up for it whenever someone requires them to pay extra money."
The syndicate published a paper on their website, which citizens can print and show to hospitals personnel. The paper called "free medical treatment is your right" including a list of the constitutional articles and cabinet decisions, which guarantee citizens' rights to free medical services.
Al-Mounira hospital witnesses increasing crowd as they started providing free medical services
(Photo by Menan Khater )
Similar to the tickets paid by citizens for other public services such as transportation, the revenues generated from public hospitals are allocated in three directions. The first is the state budget, the second is for a fund that enhances services inside hospitals, and third is for rewards and incentives to medical personnel.
Ministry of Health spokesperson Khaled Megahed told Daily News Egypt that cutting those revenues is like to leave the state to "starve".
"The state currently seeks expansion of investments, tourism, and generally aims to increase its financial resources, not to cut back revenue streams," he said.
According to Megahed, free medical treatment is a system already adopted in public hospitals, whether through health insurances or the small fees paid by patients, which he said are very small compared to the services presented.
Regarding the surplus fees required for further examinations or operations, Megahed said there are certain prices listed in the code of conduct inside hospitals for each kind of medical examination, but again those prices are trivial compared to the services – yet they are an indispensable resource in the state's budget.
"The call to implement a free of charge medical treatment is simply illegal," Megahed said, referring to the EGP 1 ticket price. The syndicate however did not call for banning this ticket, but rather called for banning the exorbitant money required for further examinations, Al-Taher said.
As soon as the syndicate decided to enforce the decision, the ministry sent illustrative memos to hospitals urging them not to implement the decision, and described doctors who will proceed with it as outlaws, highlighting potential legislative risks.
"Retribution in itself is not our goal, but rather ensuring that patients get the right in medical care and find the doctors who provide it," Megahed said. "But if such a decision results in deteriorating the services inside hospitals, due to low budget, the ministry will start implementing strict legal penalties against doctors who implemented it."
The health sector budget remains insufficient amid the ongoing challenges. Only 1.5% of the state's GNP, amounting to EGP 2.7bn, was allocated towards enhancing healthcare during fiscal year of 2014-2015; leaving only 33 beds available for every 10,000 citizens in Cairo's hospitals.