“What you see in Egypt is typical of a health system that has been neglected by the government,” said Henk Bekedam, the World Health Organization's (WHO) representative in Egypt. “And this is not since yesterday or since the revolution. This has been happening for the last 20 or 30 years.” The Egyptian government plays a marginal role in the country’s public health care system despite Egypt having the highest prevalence of hepatitis C (14.7% of the population), high rates of obesity and hypertension (17.6% of the adult population) and endemic poverty.
The health care system recently came under scrutiny after images of run-down government hospitals went viral following visits by Prime Minister Ibrahim Mahlab to two government-run hospitals June 6. The events spurred doctors to share photos revealing the alarming conditions in hospitals throughout the country. Among the images were clogged squat toilets, warnings about poisoned water, cats wandering the halls, animal droppings on hospital paperwork and bloody bandages on the floor.
On average, Egypt, the most populous country in the Arab world, invests 1.5% of its gross domestic product (GDP) on health expenditures for its 82 million citizens, who are subjected to sometimes unsafe and low-quality services. When government fails to adequately invest in health care, the private sector and market step in to fill the void, alleviating problems while also creating new ones. “The market doesn’t invest in safety and quality unless it gets a return,” Bekedam told al-Monitor.
Heba, a doctor doing her rounds at Demerdash Hospital, recalled instances where her colleagues had to act against hygiene protocols. “I’ve seen doctors treat HIV patients without gloves and deliver a baby with bare hands,” she revealed to Al-Monitor. “When there are not enough medical supplies, doctors buy them out of their own pockets.”
If only provided limited funding, health care facilities can deteriorate rapidly. Hepatitis C, transmitted blood-to-blood, is mostly spread in the health sector, where lack of resources paves the way for negligence.“If you don’t get enough money, you start reusing things you shouldn’t be reusing," Bekedam said. He continued, "You stop cleaning the floors. The curtains won't be replaced. The crack in the window will not be repaired,” as seen in the photos circulating on social media.
The new constitution mandates that government expenditures on health care increase to 3% of GDP by 2017. For Sharif, a member of the intensive care unit (ICU) team at Demerdash, investment in health should also extend to research. “We don’t have labs,” he said. “Money needs to go toward turning the hospital into a research center.”
The provision of public health care in Egypt is highly fragmented. Without one entity in charge of overseeing the sector, health care policy becomes complicated. According to a WHO presentation, a copy of which Al-Monitor secured, the Ministry of Health provides 30-35% of services, mostly through primary care clinics. The Ministry of Higher Education provides more than 30% of services through respected university hospitals. The third strand of public health care consists of independent ministries — defense, transport, aviation, electricity and interior — and the Health Insurance Organization (HIO), accounting for more than 10% of services.
To address this fragmentation, Bekedam has suggested the creation of a state health council, chaired by the prime minister, who would be able to call on ministries to coordinate and facilitate policy. In addition to the disjointed nature of the system, however, low wages are common. As Bekedam explained, “Clinicians in public hospitals are getting about 25% of the living wage from government salaries and are getting the remaining 75% from patients.” It is not uncommon for a tertiary care doctor to work two or three different jobs, jumping between the public and private sectors to pay the bills. With little incentive, clinicians are more likely to misdiagnose or overprescribe to help feed their families.
There is also a derth of coverage. “The Ministry of Health doesn’t offer incentives for doctors to go work in remote areas,” said Mahmoud, an ICU doctor at Demerdash. Thus, with the Ministry of Health struggling to staff hospitals in remote areas, like Upper Egypt, people flood into Cairo in search of medical services at government hospitals, like Demerdash.
Heba said that she can see between 200 and 300 patients in one of her typical 12-hour shifts, with only one nurse responsible for 40 patients. “Sometimes doctors also have to act as porters,” she added, so salary increases alone will not solve the problem. “The whole system needs to be changed, and doctors should appreciate the work of the staff, make them feel like their job is precious.”
The holy month of Ramadan was particularly hard for Abdallah, 23, who after finishing his compulsory military service had to take his father to Demerdash for symptoms of dysphagia (difficulty or discomfort in swallowing) and weight loss. Abdallah and his family cannot afford Demerdash's costly services, but the university hospital is one of the best in Egypt, and they are desperate. “Every year, nearly 1 million Egyptians [experience] catastrophic health expenditures,” said Bekedam.
The low value for the money characteristic of primary care clinics creates mistrust among the population. “Clinics only give painkillers,” Abdallah complained, as this results in people having to seek services in expensive tertiary care facilities for ailments that could have easily been treated in a clinic.
“A high number of our patients come for reasons like a simple cold, gastroenteritis, and diarrhea,” said Mahmoud. “They don’t know where to go, and they don’t trust clinics.” One possible solution would be for the government to begin promoting a family health model and a referral system to hospitals.
Unless you have money in your pocket, you are unable to get services in Egypt. “The market does not invest in the poor,” said Bekedam. According to law, the first 48 hours of care in an emergency room, public or private, are free. Regardless, 72% of all health care expenditures are out-of-pocket. To afford treatment for his father, Abdallah had to borrow money from family members, but he knows that even with borrowing, not everyone can afford medical treatment.
When hospitals are overcrowded, patients are referred to other facilities with available space. If they cannot afford the cost at the other hospital, nothing more can be done. The 26% of Egyptians living below the poverty line are likely to face situations in the waiting room involving life and death. Abdallah’s mother experienced this when one of her children died the day he was born because of a lack of available neonatal units at the hospital. Instead of resentment, Abdallah has succumbed to a sense of helplessness. “What can they do?” he asked, defending health care providers.
The social insurance system, administered by the HIO, allegedly covers 60% of the population. It does not, however, cover the majority of clinical services. At the moment, only 6% of health expenditures are covered by the HIO.
The government plans to put the health care system under the knife with a series of reforms. By 2030, Egypt expects to implement a system of universal health insurance for every Egyptian. The system seeks to create a separate body [to disburse payments] that replaces the direct payment of patients to providers. "The body, in turn, will argue in the patient’s behalf to get better services and better quality, for a better price,” Bekedam told Al-Monitor.
Raising wages, guarding safety, improving services and instituting universal health care will not amend the systemic faults — such as administration, structuring and graft — in Egypt's health care system. For this reason, health care providers must play an active role in reforming the sector, while policymakers have to ensure the public is educated, so they can demand better and affordable services.
Back in Bekedam's office, nestled in the Ministry of Health, the WHO representative sees “hopeful times” ahead. Not so far from the ministry in a coffeeshop engulfed in the city’s loud nightlife, Abdallah is hopeful that his father's next visit to Demerdash will improve his health, even if he cannot afford it.
Note: The names of the health care providers at Demerdash Hospital have been changed.