One morning in March, Noha, a 30-year-old woman, arrived to the reception desk in al-Mabra Hospital in Port Said with a severe stomachache. She had to wait for half an hour in the outpatient clinic. The doctor assigned to the morning shift did not show up, so someone had to call the night shift doctor to come instead. The doctor conducted a quick examination of Noha, then he asked her to do outpatient pelvic and abdominal ultrasounds — but she would have only one hour to return with the results before he had to perform a surgery.
Al-Mabra Hospital, one of the main hospitals in Port Said, has been selected for the city’s first phase of the pilot of Egypt’s new healthcare insurance system, which launched in early July and is set to end in 2020. Noha is one of the hundreds of thousands of people who will be insured under Egypt’s new comprehensive healthcare insurance system, which, unlike the old system, is to cover the entire population.
A coastal city north of the Suez Canal with a population of around 750,000, Port Said is a good test site for the experimental new healthcare system. Many of the densely populated city’s residents cannot afford to pay for health insurance: only 60 percent of Port Said residents pay for the old healthcare scheme, according to Ayman Rakham, a member of the team overseeing the implementation process of the new system. For Alaa Ghannam, a member of the committee that drafted the comprehensive healthcare insurance bill and the director of the Right to Health program at the Egyptian Initiative for Personal Rights, this setup offers a good opportunity to evaluate and improve the system.
The city is divided into seven neighborhoods, two of which are in the more affluent old city: al-Sharq and al-Arab, which is a popular commercial district. The other five neighborhoods are newer and consist mostly of low-income housing, which reflects the socioeconomic class of most inhabitants.
Noha’s diagnostic tests cost LE70, but she does not have health insurance. Her other option was to sign up and wait her turn in the public al-Amiri Hospital — the other large hospital in Port Said — to get tested a week later. Distraught, she pulled herself together and went to al-Amiri Hospital, only to find that the hospital does not offer the tests she needed. She decided to borrow money and get the tests at al-Mabra.
In Port Said, there are 11 public hospitals and three private hospitals. Sixty-five percent of public hospitals filed for accreditation under the new healthcare system, according to Ashraf Ismail, the head of the Accreditation and Supervision Authority, which is responsible for accrediting qualified hospitals and health units under the new system. The Finance and Health ministries worked together to equip those hospitals to administer the new healthcare system, and a few months ago, the Port Said Health Department announced that al-Amiri and al-Zuhoor public hospitals would be partially closed for upgrades ahead of the pilot launch. The renovation work in both hospitals has continued during the pilot.
In order to address the lack of resources at some public hospitals, the new healthcare system allows the private sector to partner with the public sector to offer medical services. And all healthcare units, both private and public, must meet minimum standards of quality for acceptance into the new health insurance system.
In June, the Accreditation and Supervision Authority for the new health insurance system announced that it had finished drafting the quality standards for hospitals, primary care clinics, pharmacies, and medical laboratories.
Additionally, last March, the Ministry of Health announced that public hospitals will sign a twinning protocol with private hospitals to implement the management strategy of the new healthcare system and train government sector health workers.
Cleopatra, Maghraby Eye Hospital, al-Salam International Hospital, and Dar al-Fouad are among the private hospitals that signed the twinning protocol to train health practitioners in Port Said’s public hospitals.
The twinning protocols came after the government expressed its desire to forego the administration of public hospitals. But Minister of Health Hala Zayed explicitly denied that the twinning protocol will pave the way for privatization. Rather, these agreements are only meant to establish the grounds of “partnership and integration,” as she put it.
But Mona Mina, a Doctors Syndicate councilmember, is concerned about the consequences of such partnerships. Staff at some public hospitals will be excluded from the opportunity to receive adequate training, which will make it impossible for them to receive accreditation under the new healthcare system, Mina says. For the councilmember, this is an early indicator that such hospitals will either shut down or be privatized.
A 50-year-old woman stands in front of the clinic at al-Mabra Hospital, holding her file. She came here after she was diagnosed with coronary artery disease at a private clinic. She needs to use a catheter and buy prescription drugs that cost LE350 — an amount that she cannot afford. When she went to the public al-Amiri Hospital to receive the medication and prepare for surgery, the doctor read the woman’s prescription, but he only approved two of the six prescribed drugs for pickup— the only two available in pharmacies. One was Aspocid, a popular aspirin that only costs LE7. The medication she urgently needed to prevent heart attacks was not available.
According to a pharmacist based in Port Said who spoke to Mada Masr on condition of anonymity, the registered drugs list for pharmacies was updated a few months before the launch of the pilot. The previous list included 115 drugs. Twenty new drugs were added, including diabetes and blood pressure medications that were not available before. However, important drugs for chronic heart diseases and strokes remain absent from the list.
Doctors are also in short supply, which is an ongoing problem in Egypt. According to Rakham, there are 375 physicians registered with the Port Said Health Department. This means the city has only one doctor for every 2,000 residents, half of the World Health Organization’s recommended minimum of one doctor per 1,000 residents.
Rakham told Mada Masr that the Ministry of Health aims to increase the number of doctors in Port Said to 1,000 by the end of the pilot. The new Health Insurance Authority, responsible for managing and financing the healthcare system, interviewed 1,200 doctors from outside Port Said, according to media reports, but didn’t announce the number of contracts with doctors it actually signed. Some doctors who spoke to Mada Masr said that the authority signed contracts with salaries of up to LE13,000 per month.
Egypt’s doctor shortage crisis is worst in the public sector, largely due to low pay, leading many doctors with public sector contracts to take continuous unpaid leave, or ultimately to resign.
According to official estimates, the new healthcare system will cost LE600 billion over 15 years. The new system will be financed through different channels, including the fees of privately and employer-insured citizens, who are covered by their employers and will also see part of their insurance fees deducted from their net salaries. The new system will also require citizens with higher income to pay higher fees, thus ensuring equitable coverage. The system will also be financed with fees on various services, including on driver’s license issuance and renewals and healthcare facilities, taxes on commodities, such as fuel and cigarettes, and on industries, including cement and iron, as well as a 0.25% to 0.5% tax on the annual revenues of all companies.
Estimates provided by Parliament’s joint committee on Health, Legislative Planning and Budget Affairs show that 30% of the population cannot afford to pay for health insurance. In other words, the government will have to cover the health insurance costs of 30 million people. According to the Ministry of Health, if the average annual cost per insured person is LE1300, then the government will pay about LE40 billion per year for those who cannot afford the fees, once the system is implemented across the country. Meanwhile, the treasury has committed to covering health insurance for those unable to afford it at a rate of 5% of the national minimum wage for each person.
The recently released results of the government’s latest biannual population study show that nearly a third of Egyptians live below the poverty line, which is close to the 30 million people the government estimates it needs to insure.
Minister of Health Zayed requested LE17 billion from Parliament’s budget committee to be allocated for the health insurance pilot program. The budget committee refused Zayed’s request, and instead allocated LE1.3 billion from the state budget. The money will only cover insurance fees the segment of the population in the pilot program that cannot afford to pay them.
Mina expressed concern that the law does not specify an adequate mechanism to determine who cannot afford insurance fees. Ghannam believes this problem will continue to pose a major challenge to implementing the new healthcare system. It is unclear what indicators are being used, or who has the mandate to set the criteria of such category. The matter becomes more difficult due to Egypt’s vast informal economy; there are no reliable statistics on the incomes of people working in the informal sector.
However, Ghannam asserts that the challenge is not insurmountable. He points out that there are 23 existing indicators used to measure income. They include electricity and water consumption, household spending, and the number of out-of-school children a family has. Ghannam adds that the law also considers people with chronic diseases and pensioners eligible for state-funded health insurance.
Although the state treasury will cover a large portion of the expenses, Ghannam believes that enforcing insurance fee payment among privately and employer-insured citizens is the key factor determining the success of such a massive project.
The new healthcare system is enshrined in the Constitution and is one of the main components of Egypt’s sustainable development strategy, dubbed Egypt Vision 2030. A year and a half ago, Parliament passed the new health insurance bill to unify all existing public health insurance schemes under one comprehensive system for all Egyptians.
Broadly, and despite the difficulties, Ghannam believes that the new health insurance system should be seen as an optimistic, experimental project. He points out that the law is the product of five arduous, previous attempts since 1999.
“It is more fair to pay attention to the enormous effort that has been put into drafting the law. Implementation is a process that will continue to develop, and flaws will continue to be addressed as they arise.”