Egypt and Iraq ranked amongst the 20 worst performing countries in the field of health according to the new World Classification of 2019. The Indigo Wellness Index – which collects data for this classification – is one of the most comprehensive indicators, covering 191 countries around the world.
While Iraq ranked ninth in poor health performance, Egypt ranked 18th (among the 20 worst-performing countries in health). The index is ranked in descending order, ranking first in the worst-performing country to reach the most powerful country in the world, which gave status 191. The index attributed the occupation of Egypt to this late status to the lack of government spending on health care and increased risk of diabetes, and rates of obesity.
However, the Egyptian government did not care much about this global health index and its results; as the Egyptian arena has been heavily preoccupied with Abdel-Fattah Al-Sisi’s constitutional amendments and their immediate and future consequences. Regardless of the debate on the constitutionality of these amendments, they unfortunately did not address any issues related to the citizen’s daily life, especially in the field of health care.
This paper addresses some basic concepts about the Egyptian health policies and strategies, their application procedures on the ground and how far they are adhering to the provisions of the Constitution of 2014, and whether there was a need to include health articles in Sisi’s constitutional amendments?
First axis: Health policies and systems and how far Egypt is adhering to them:
1) Health policies and systems:
According to the World Health Organization, “The mismatch between actual performance of fragmented health systems and the rising expectations of society is becoming a cause of concern and internal pressure for health authorities and political leaders. These and other factors – including today’s consensus around the importance of realistic costing and strong monitoring and evaluation – have translated into a renewed focus on strengthening countries’ capacity to develop robust national health policies, strategies, and plans that can:
- Respond to growing calls for strengthening health systems through Primary Health Care as a way of achieving the goal of better health for all. This requires action in four policy areas:
- Moving towards universal coverage,
- Reorienting conventional care towards people-centred care,
- Integrating health in all policies,
- And ensuring more inclusive health governance;
- Guide and steer the entire, pluralist health sector rather than being limited to command-and-control plans for the public sector alone;
- Go beyond the boundaries of health systems, addressing the social determinants of health and the interaction between the health sector and other sectors in society.
Thus, health policy can easily be defined as “plans developed by states and societies for designing, structuring and strengthening health care systems that would enhance the health of individuals and communities.” However, the health system is characterized by provision of health and preventive services as well as the community role that low-income states depend on for achieving social justice that cannot be achieved without the due attention paid by health policymakers and decision-makers to socially marginalized and low-income segments, taking into consideration that these people are more susceptible to disease, given their lack of any health awareness.
On 16 December 1966, the United Nations General Assembly adopted the so-called International Covenant on Economic, Social and Cultural Rights (ICESCR), including the right to health. Article 12 of the ICESCR stated that “states parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” This can only be achieved through a comprehensive system of health care that should be available to everyone without distinction; this system should not be restricted to only providing timely and appropriate health care, but it should also address the basic determinants of health such as access to safe drinking water, appropriate sanitary drainage and enough supplies of foodstuff, nutrition and housing, in addition to appropriate health, vocational and environmental circumstances. The ICESCR that was signed by Egypt in 1967 and ratified in 1982 states that for achievement of full realization of right to health, the steps to be taken by states parties to the Covenant should include the following:
(a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;
(b) The improvement of all aspects of environmental and industrial hygiene;
(c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
(d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.
2) Health situation between launching initiatives and neglecting strategies:
In 2014, in parallel with the meetings of the Committee of 50 for the drafting the Constitution, the Ministry of Health issued a health policy paper under the title “White Paper: Outlining Health Policy in the Arab Republic of Egypt”, which stated that “Many of the challenges facing Egypt’s health sector are interlinked and tackling them one by one is neither effective nor efficient. As such, the guiding principles and strategic directions that should determine the path forward will need to reflect a holistic approach, where the whole range of issues and challenges are tackled comprehensively, strategically and horizontally.” It also stated that “Dialogue will need to be broadened beyond the public sector and beyond the health sector. This policy dialogue must also aim to promote behavior change among development partners to encourage them to align and harmonize their activities, for:
a- Achieving better and equitable Health outcomes
Health is a fundamental human right of all Egyptians. The overarching goal of a National Health Policy is to improve the health of the entire population. Improving health is an intrinsic goal in itself but is also an important pathway to supporting poverty reduction and the socio‐economic development of Egypt.
b- Protecting and promoting health and ensuring access to essential health services for all with financial risk protection (Universal Health Coverage)
By 2030, Egypt must move towards ensuring access to quality health services for everyone and ensuring that no one suffers financial hardship for health payments. The National Health Policy must ensure the availability of health services and upgrade their quality, so that access to required services is not hindered by financial barriers (such as consultation fees or medicine prices that are beyond the capacity of individuals to pay) or non‐financial barriers (geographical, information‐based, gender‐related, or any other sort of discrimination or stigma). Meanwhile, mechanisms for protection against financial risk should be put in place so that nobody is pushed in to hardship or poverty in order to pay for health services.
c- Strengthened role of the government in providing public health services
The role of the state should be fundamental and central to achieving health goals. The government’s role needs to be strengthened both in the provision of public health services and in increasing investment to correct market failures. This includes improving the safety and quality of public health services with a focus on the key health priorities: Hepatitis C, NCDs, MCH, Influenza, Nutrition, etc. Adequate public funding for good quality research that will support public health goals must also be ensured.
d- Ensuring effective national governance to address the multisectoral aspects of health and to deal with health sector fragmentation
National health policies, strategies and plans will need to promote the inclusion of the different dimensions of health within a general governance framework that is constructed with adequate legal, regulatory and institutional elements. The new Constitution addresses many issues related to health that are beyond the scope of the Ministry of Health and Population and the health sector at large. This reinforces the need to address the social determinants of health in a multisectoral framework.
e- More money for Health (new Constitution) and More Health for the money (efficiency)
The current low level of public investment in health has led to high levels of out‐of‐pocket health expenditure and has reinforced domination of market forces through the increased involvement of the private sector and a general commercialization of health services.
f- Accountability and transparency
Accountability needs to be ensured by improving transparency around decision‐making, resource use, and results. This requires the development of well‐established, transparent processes for monitoring progress through improved data collection, analysis and dissemination. It also requires that the community be given the opportunity to access information, and that civil society is actively involved in the monitoring process. Strategic and operational plans need to be implemented based on a step‐by‐step approach, where there is a clear vision of the way forward but where a system is established for monitoring health sector performance with measurable indicators and targets.
g- Involving all stakeholders in the process including, civil society and the private sector
National Health Policies, Strategies and Plans are more robust and more likely to be implemented effectively if their development is inclusive of all relevant stakeholders, within and beyond the health sector and within and beyond the government. Civil society should be brought in as a key player in policy and strategy making and also in monitoring and ensuring social accountability. The private sector, (for profit and not‐for profit) is a major component of the health sector and need to be included in the policy and planning process.
Despite the significance of increasing government financing and need for development of an integrated plan covering all axes, programs and activities, the health reality has tended to be indiscriminate in implementation under the slogan of “Presidential Health Initiatives”, which have expanded and dominated the current Egyptian health situation, such as:
1) The initiative to solve the problem of waiting lists for surgical operations,
2) The “100 million ‘get well soon’ initiative” with its three axes: the medical survey of C virus, the medical survey of obesity, and the medical survey of diabetes,
3) The ‘Nour Hayah’ (life light) initiative for countering blindness,
4) The renal dialysis unit initiative,
5) The initiative to detect anemia, obesity and stunting among schoolchildren,
6) The initiative to detect breast cancer in women,
7) And the initiative of “interest in girls”.
The initiative to solve the problem of waiting lists for surgical operations is an significant example for showing how the impact of this trend on the health situation in Egypt is extremely dangerous. Accumulation of patients on the waiting lists for surgical operations is a real problem that emerged after the government had confiscated a large number of hospitals and health centers belonging to charities such as the Islamic Medical Association (30 hospitals and medical centers spread in seven governorates) the Shari’a Society and Young Muslims Association, leaving the government-run hospitals alone, facing a problem that is much greater than its absorptive capacity.
In one of his speeches in December 2018, Sisi announced that the problem of the waiting lists had been solved with the help of the army and university hospitals, considering this a success. Here, there is a serious observation, i.e. that the army’s entry for solving the problem means that the health ministry hospitals have not been developed and modernized. The problem also aggravated as the funds used in financing these surgical operations was provided by the Ministry of Health and directed entirely to the army and university hospitals, wasting the citizen’s right to receive a daily health service, that was financed by these funds.
On the other hand, the waiting lists problem uncovered the decision makers’ lack of accurate data on the health situation in Egypt: At first, Sisi declared that the problem had emerged with 18,000 patients on the waiting lists, but with starting to address it the number reached 50,000. Later, the Minister of Health announced that there are 132 thousand patients on the surgery waiting lists. Dr. Khaled Samir, a professor of cardiothoracic surgery at Ain Shams University and a member of the former board of the Egyptian Doctors Association, wondered whether there was a scientific study on the causes of the waiting lists or even a feasibility study to show the cost needed to bridge the gap and the required annual budget and time plan for solving the problem and preventing its re-emergence.
In fact, the problem was faced without relying on any surveys for the health situation on the ground and in absence of clear and accurate statistics on the size of the problem, which aggravates the disaster of indiscriminate moves for solving current health problems in Egypt amid complete absence of any strategies or procedures to achieve specific targets in a certain time.
Second Axis:Health care articles between the 2012 Constitution and 2014 Constitution:
Article 18 of the 2014 Constitution on health and its related supplementary articles (33, 34, and 238) were promoted by the pro-regime media as an important achievement and that they are more comprehensive and specific in terms of the health budget and the rights of citizens, as well as interest in the health team than Article 62 of the 2012 Constitution and its supplementary articles (22 and 24), which have unfortunately been grossly violated and neglected over the past five years.
Article 62 of the 2012 Constitution states that:
“Healthcare is a right of every citizen. The state allocates a sufficient percentage of the national revenue to healthcare. The state provides healthcare services and health insurance in accordance with just and high standards, to be free of charge for indigents. All health facilities provide various forms of medical treatment to every citizen in cases of emergency or danger to the life of a person. The state supervises all health facilities, inspect them for quality of services, and monitor all materials, products and means of health-related publicity. Legislation will be issued, and measures will be passed to put such supervision into effect.”
Article 18 of the 2014 Constitution states that:
“Every citizen is entitled to health and to comprehensive health care with quality criteria. The state guarantees to maintain and support public health facilities that provide health services to the people, and work on enhancing their efficiency and their fair geographical distribution.
The state commits to allocate a percentage of government expenditure that is no less than 3% of Gross Domestic Product (GDP) to health. The percentage will gradually increase to reach global rates.
The state commits to the establishment of a comprehensive health care system for all Egyptians covering all diseases. The contribution of citizens to its subscriptions or their exemption therefrom is based on their income rates.
Denying any form of medical treatment to any human in emergency or life-threatening situations is a crime.
The state commits to improving the conditions of physicians, nursing staff, and health sector workers, and achieving equity for them.
All health facilities and health related products, materials, and health-related means of advertisement are subject to state oversight. The state encourages the participation of the private and public sectors in providing health care services as per the law.”
Third Axis:
A field study of the reality of health care in Egypt over the past five years in light of provisions of the 2014 Constitution:
First: Decline of Government Expenses on Health Care
During his meeting with members of the Health Committee in the House of Representatives, former Minister of Health Ahmed Emad El-Din revealed that the Ministry of Finance had contracted with one of the well-known and accredited companies to analyze the current health situation in Egypt, where they found out that 70% of the health system depended on patients’ pockets because of the low budget of the health ministry that cannot address the health burden (in a human way). This can be illustrated as follows:
1- Low health budget:
While Article 18 of the 2014 Constitution establishes the right of every citizen to health care according to quality standards, the Indigo Wellness Index has ranked Egypt and Iraq among the worst 20 countries in the world health rating. The index attributed the occupation of Egypt to this late status to the lack of government spending on health care and increased risk of diabetes, and rates of obesity. The index focused on the government’s low spending on health care in Egypt, which is a reality. The health budget for the current fiscal year 2018/2019 reached 61.8 billion Egyptian pounds, including 16 billion pounds that were allocated for water and sanitary drainage. Thus, government spending on health is only 1.2% of the expected GDP, less than one third of the rate scheduled in 2014, which was supposed to start from 3% and gradually rise to conform with global rates i.e. at least 7-10% for the current fiscal year (not only 1.2% as officially announced). Article 238 of the 2014 Constitution stipulates that: “The state shall gradually implement its commitment to the allocation of the minimum government expenditure rates on education, higher education, health and scientific research that are stipulated in this Constitution as of the date that it comes into effect. It shall be fully committed to it in the state budget of the fiscal year 2016/2017.” However, this was not done in due time as Article 238 of the 2014 Constitution states.
According to the GDP, the government spending on health should be 156 billion pounds, not 61.8 billion, as reflected in the health budget for the current fiscal year. Thus, it is clear that the proportion of health expenditure to the Gross Domestic Product is less than 50% of the rate stated in the Constitution. Also, it is evident that there is a continued decline compared to previous years.
Over the past few years, health care has faced several crises, such as:
– Crisis of subsidized infant milk and intervention of the army,
– The crisis of shortage in intravenous solutions (salt, drought and glucose solutions), against the backdrop of suspension of the local supplies by a number of companies and factories due to the high dollar exchange rate, thus increasing their prices by 60%.
– The price rise of 3 thousand drugs out of the seven thousand medicinal products traded in the Egyptian market, twice in less than two years, which led to the suffering of citizens because of the non-availability of several types of drugs exceeding 1650, including 250 drugs without available alternatives.
The decline in health budget allocations raises concerns after reducing subsidies for the infant milk and vital medicines, leading to continued suffering of many people over the past two years. According to the Central Agency for Public Mobilization and Statistics (CAPMAS) report for 2016, 27.8% of Egyptians are poor and cannot meet their basic needs, including, of course, health needs.
The results of the 2017 national health survey carried out by CAPMAS revealed that 85% of deaths in Egypt were caused by non-communicable diseases such as blood pressure, diabetes and obesity, and that 90% of Egyptians are at risk of infection. A report by Colliers International in 2014 said that the per capita health expenditure was US$ 178 (with a total estimated expense of US$ 16 billion on the healthcare sector) compared to more than US$ 1000 in most of the Gulf countries: For example, the health expenditure per capita in the United Arab Emirates is US$ 1611. In Switzerland, the per capita spending on health is US$ 9,674, and in the United Kingdom it is US$ 3935. In 2014, Egypt ranked 97th out of 144 countries in achieving the basic health and basic education requirements. In 2016, Egypt ranked 186th out of 220 countries through the statistics of the Numbeo website, which monitors the welfare of countries.
2- Dependence on loans and donations:
the so-called ‘presidential initiatives for health’ was launched amid a great media hype, but the most important is that the funding was not from the state budget, but came from other sources that do not have any kind of permanence or continuity, such as:
a) The “100 million ‘get well soon’ initiative”, the medical survey of hepatitis C, obesity, diabetes and noncommunicable diseases that included 50 million Egyptian citizens, was financed through a loan from the World Bank.
b) Nour Hayat initiative to combat blindness was funded by one billion pounds from the “Tahya Masr” (Long live Egypt) fund of donations.
c) The renal dialysis unit initiative for establishing 1,000 kidney dialysis units was funded through one billion pounds from the “Tahya Masr” (Long live Egypt) fund.
3- Lack of quality and dissatisfaction of citizens about the health service:
The decline in government spending on health has led to a significant decline in the infrastructure required for the provision of health services. In 2016, a health survey carried out by the National Council for Criminal and Social Research, an Egyptian government institution, stated that that 61% of Egyptians are not satisfied with the government health services compared to 39% that were satisfied at varying degrees.
4- Privatization of hospitals:
Many hospitals were privatized, such as the Qasr al-Eini University Hospital and other health integration hospitals, medical institutions that perform examinations and minor surgeries before sending the patient to a central hospital or a university hospital if necessary.
This violates three of the 2014 Constitution provisions:
- Article 18 states that “The state guarantees to maintain and support public health facilities that provide health services to the people, and work on enhancing their efficiency and their fair geographical distribution.”
- Article 33 states the “The state protects ownership, which is three types: public ownership, private ownership, and cooperative ownership.”
- Article 34 states that “Public property is inviolable and may not be infringed upon. It is the duty of every citizen to protect it in accordance with the law.”
5- Absence of the comprehensive social health insurance umbrella and non-application of the new law:
Although Article 18 of the Constitution of 2014 stipulates that “The state commits to the establishment of a comprehensive health care system for all Egyptians covering all diseases”, and in spite of the fact that the parliament ratified the new Health Insurance Law in November 2017 and published in the Official Gazette Issue No. 2 of 2018, and that its Executive Regulation was issued in May 2018, its implementation on the ground is still faltering in its first phase.
6- Undermining the rights of the medical team:
Article 18 of the 2014 Constitution states that “The state commits to improving the conditions of physicians, nursing staff, and health sector workers, and achieving equity for them.” The Minister of Health announced in September 2018 that 60% of physicians had left Egypt and traveled abroad in search of good jobs. The Nursing Professions Syndicate has also announced that there is a major deficit in the government hospitals nursing staff because they prefer to work in the private sector or to travel abroad. In fact, the bad conditions of physicians and nursing staff in Egypt is a stark example of the State’s failure to comply with the 2014 Constitution.
Conclusion
While countries worldwide are committed to providing all the financial, material and moral resources for supporting health and education, as they are considered the two wings of progress and prosperity of society, however, the Egyptian regime has ignored that important constitutional priority, and the recent constitutional amendments came void of any reference to improvement of health care, leaving Article 18 of the 2014 Constitution unchanged. It was assumed that the proportion of the state’s financial allocations for financing the health care would be raised up to 7-10% of the GDP, in order to commensurate with the global rates, five years after the transitional period as stated by the Constitution of 2014, which indicates the state’s apparent lack of interest in health care.
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